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Home My Public Portal About6513 OAK AVE_Miscellaneous__ .1VORKFiRS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION nsure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS G�^� Certified copy is hereby furnished. BUILDESSING 3 LOCALITY ADDROak Ak Certified copy is filed with the county building inspection LOCALITY NEAREST department. Tem le Cit Ca. 91780 CROSS Sr. Date Applicant NEAREST DISTRICT NO. GROUP TYPE R ESSEkD BY CROSS ST. �t0 /, CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r COMPENSATION INSURANCE DESCRIPTION LOT NO. J_ BLOCK pNOF -3_ r HIGHWAY STATE MAJOR SECOND L '.,�y` "` NO. OF BLDGS. (This section need not be completed if the work involved TRACT •} NOW ON LOT US ZE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) Al USE OF SIZE OF LOT EXISTING BLDG. } I certify that in the performance of the work for which this 0 permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 3 0 ADDRESS Same as above r Date Applicant O_ TEL' OCCUPANT LOAD O_ NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. _ C-13 Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl. 0 deemed revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY IN SPECTION�' Panic Devices I hereby affirm that I am licensed under provisio ns o f Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code,and my license is in full force and a ^I I effect. r:+�/ W PARKING REQ'D SPACES PROVIDED IBJ J LL��JJ License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSSPE CATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No.. Date r HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is // issued(Sec. 3097,Civ.C.). i s I ,j Si ri 6 ec, Lender's Name Q PROPOSED MAX. COC. -8 6 6 6 P Lender's Address PERMIT FEE � � � o o O O I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE .1 - - 8(150 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter I TOTAL FEE on a above-mentioned pro rty for inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE C D C S�`5 0 Signature of Perm' tee Dat - COUNTY OF.:LOS ANGELES :'DEPARTMENT OF•PUBLIC WORKS . ' E: , MICROF.ILM 'INFORMATION R e cord RSearch Building Address Locality Tract No's. Lot No.� Lot'"Size -' p or 2 o o BuildingQ Permit # Issue.Date:a ez3. :Final- .Date Z -- DecriRtonof_1K ork-4.Gl Sq. Ft.'3S X 43 Permit # 531.393 'Issue Date Final Date �'.zF Description of work , 'Building Permit # Issue _Date Final Date Description of work Sq. Ft. Building Permit # Issue Date Final Date - Description of work Sq.. Ft. -Building-Permit--# - issue Date. Final .Date -Description of work Scl. Ft.. Note: The information given is taken from Building Permit -Records. Unless -an Oeeupancy '.Insp.ection .is requested and the fee for this ,inspection is paid-, no investigation of the property will be made by .this. Department. Sewer Permit, # Issue Date Connected to • sewer. in street: 'Inspection Date SeniorClerk