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HomeMy Public PortalAbout10011 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereyy affirm that 1 have certificate of consent to self COUNTY OF ]LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or e.n certified copy thereof(Sec.. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS CJ ❑ Certified copy is hereby furnished. uILDING LOCALITY �, F] Certified copy is filed with the county building inspection ADDRESS NEAREST department. LOCALITY CROSS ST. Date Applicant EAREST DISTRICT G OUP TYPE PRO ED BY CROSS ST. /Y\ S' 15*'X CONSto T,/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ` V COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP _ 6 HIGHWAY } STATE MAJOR SEG D LOCAL NO. (CIRCLE) d NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE 10PNE SPE IAL CONDITIONS V by the permit is for one hundred .dollars (S100) or less.) USE OF 7� SIZE OF LOT E IS INC B DG. V I certify that in the performance of the work for which this Q permit is issued, I shall not employ any person in any manner WNER —� V so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP LL ADDRESS a N Date Applicant U) rEL. NOTICE TO APPLICANT: If, after making this Certificate of OCCUPANT LOAD circ No. ( J 3 .+ �$ 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 ❑ C] No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION Icy Panic Devices LICENSED CONTRACTORS DECLARATION yr I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- El ness and Professions Code, and my license is in full force and PARKING. effect. SPACES ' REO'D O PROVIDED D License Number Lic.Class LIMITED TIME USE Contractor Date O ATE OATIE ❑ I am exempt from the licensing requirements as I am a. FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 1GNAT E iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING Lic.or Reg.No. Date NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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 e I, as owner of the property, will do the work and the SPACES PROVIDED ;24668A structure is not intended or offered for sale (Section 7044, Business and Professions Code). o0 0 o 0 S 8rosED USE OF BUILDING 1 _ \vQ� CONSTRUCTION LENDING AGENCY0 0 0 0 0 0 o z I hereby affirm that there is a construction lending agency \ 0.520-86 for the performance of the work for which this permit is issued(Sec. 3097.Civ.C.). Lender's NameT�ti. AT� �� PROPOSED MAX. OCC. Lender's Address ��yy�Z� L�pi�.L PERMIT FEE I certify that I hEiW..O'this' plica ion an ('aote t tat the above information is correct.I agree to comply with all County ISSUANCE FEE _ordinances and State laws relating to building construction, TOTAL FEE and hereby uthorize representative of this County to enter upon the ve-mentioned propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Wptealu're of P nittee Date WORKERS'COMPENSATION DECLARATION CE 875(1 1-84) MISCELLANEOUS A P P L I C AT I O N hereby affirm`that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,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. BUILDING LOCALITY PLC ADOR ESS / Certified copy is filed with the county building inspection LOCALITY- e NEAREST department.UYY � �� M1 CROSS ST. Date Applicant NEAREST D RI TYPE OCES D BY ` CROSS CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION L04 NO. BLOCK NOP (CIRCCLp�) STATE MAJOR SE CO D LOCAL ' NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CON (TIONS by the permit is for one hundred dollars ($100) or less.) USE OF a I certify that in t e performance of the work for which this SIZE OF LOT EXISTING BLDG. permit is issued, I shall not employ any person in any manner OWNER' S t° � so as to become subject to the Workers' Compensation Laws. nonREssK — �� � ►� OCCUPANCY GROUP Date A plicant ill, NOTICE TO APPLIC T: If, after making this Certificate of clrY No� -yS�Z OCCUPANT LOAD T Exemption, you sliou d become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provision of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE I] GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONT CTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 0 I hereby affirm that I am li ensed under provisions of Chapter J(1ame-bF SAFETY PERMIT ❑ (LIST ITEMS BELOW 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,a d my license is in full force and �; 5 effect. ! { 1 G0 1 PARKING REQ•D � PR VIDED _ SPACES License Number Lic. Class G LIMITED TIME USE Contractor ate DATE DATE FROM: TO: I am exempt from the licens requirements as I am a licensed architect or a regist red professional engineer SIZE OF C NO. OF pSPECTO acting in my professional cap city (Section 7051, Bus- EXISTING BLDG. �)L/ STORIES S,-NATO E iness and Professions Code). PRESENT USE OF BUILDING ���� FINAL APPROVALI AU19 Lic.or Reg.No. Date v , HOME OWNER-BUILDER DE LARATION NO. OF EXISTING BUILDINGSp.11 ON LOT AND USE 0E I Hereby affirm that I am exempt fr \tion Contractor's License Law for the following reason (S031.5, Busi- ness ness and Professions Code): NO. PARKING SPACES PROVIDED I, as owner of the property, will dork and the 1]06 1 pM ?o2q structure is not intended or offerale (Section 7044,Business and Professions Code)CONSTRUCTION LENDING APROPOSED USE OF BUILDING ( 1I Hereby affirm that there is a construcding agency for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE — 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 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE aS-- upon the above-mentioned property for inspection purposes. /q SEE REVERSE FOR EXPLANATORY LANGUAGE _61X-6• 12912- Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). /[ _ Policy No. Company FOR APPLICANT TO FILL-IN ADDRESS a/ Certified copy is hereby furnished. BDDRESS �UILDING � 1 / l �� LOCALITY G..� /�s / V Certified copy is filed with the county building inspection LOCALITY /� NEAREST department. 1n („�a CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PRO SSED BY CROSS ST. 1;��� CONS¢'/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL aaJJ V COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP (CIRC AY STATE MAJOR SE CO D LOCAL NO, (CIp CLE) NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of IZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 4OWNER D SP so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP Lam=J o Date Applicant JAD13RESS �Jf�?,� W NOTICE TO APPLICANT: If, after making this Certificate ofITY /Y i/m NO. OCCUPANT LOAD612 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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. F] ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness No. of EXITS and Professions Code,and my license is in full force and effect. PARKING REO'D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer slzr.OF NO.OF INSP CTOR'S acting in my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES SI ATURE iness and Professions Code). Lic.or Reg.No. Date PRESENT USE OF BUILDING � g� FINAL APPROVAL 4VW 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- o 0 o 0 0 0 o z ness and Professions Code): NO. PARKING 0 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 0 $8 6 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDI 4.EES C4I5, 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.Q. Lender's Name U PROPOSED MAX. OCC. CI \ Lender's Address �hI PERMIT FEE �VV I certify that I have read this application and state that the abov ormation is correct.I agree to comply with all County ISSUANCE FEE ord'kereb and St a60 a laws relating to building construction, ^ and aut or' representatives of this County to enter TOTAL FEE CA I 00e ab ve- en 'oned pro rty for inspection purposps. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature o ermittee Date WORKERS'COMPENSATION DECLARATION 20-00 3DPW12/90 M15CEL1LAN EOU,,S APPLICATION I hereby affirm that I have a certificate of consent tb self COUNTY OF LOS ANGELES r BUILDING AND SAFETY DIVISION -;insure,or a certificate of.Workers'Compensation Insurance,or a certified copy thereof(Seo. 3800, Lab.C.)• (� Policy No. Company FOR APPLICANT TO FILL IN BUILDING SU L LNG DDRE ADDRESS Certified copy.is hereby.furnished. X CALITY t ! Certified copy is filed with the county building inspection CXc. NEAREST rtm I depaenL / f t ZIP / O CJ CROSS ST. Date `• _Applicant SIZE OF LOr NO.OF SLOGS.NOW ON LOT DISTRICT NO. GROUP TYPEPROCESSED BY G CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. HIGHWAY C i ! COMPENSATION INSURANCE NOP (C RCLM STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCELOI by the permit is for one hundred dollars (S100) or less.) USE ZONE SPECIAL CONDITIONS C T LW=VWt- ( I certify that in the performance.of the work for which this e r permit is issued. I shall not employ any person in any manner I so as to become subject to the Workers' Compensation Laws. ArL � OCCUPANCY GROUP ( ) Date Applicant . I Zlq p 0 t NOTICE TO APPLICANT: If, after making this Certificate �' I OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE: comply with Such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ 1 No Spec.Know[. revoked. ❑ • •OCCUPANCY INSPECTION[ Panic Devices ElLICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) ' a I ! 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS and Professions Code,and my license is in full force and effect. Name po nes ess License Numbe) LIC CISSS /•��J f/�) C SPACES PARKING• REWD � PROVIDED I ( I Contractor — Date r `•J LIMITED TIME USE JJ ' i El I am exem it from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM: To: acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S �• and Professions Code). EXISTING BLDG. STORIES SIGNA RF— Lia or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL WWI i HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS I ON LAT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): NO.PARKING SPACES PROVIDED i ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING Business and Professions Code). I I i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ( I (Sea 3097,Civ.C.). PROPOSED MAX.OCC. Lender's Name_ A —rull 1W r L ' Lender's Address D s �^ LLI certify that I have read this application and state that the S—r' above information is correct. I agree to comply with all County PERMIT FEE ordinances and Slate laws relating to building construction,and - hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentic ned property for inspection purposes. I •.S /n -{-�/�) TOTAL FEE /Yy• lY c/ LC % SEE REVERSE FOR EXPLANATORY LANGUAGE Sigt#u e of Permittee Date WORKERS'COMPENSATION DECLARATION 75M4" ICE 875(11-84) M ISCELLAREOUS APPLICATION 1 hereby affirm that I have a certificate of consent to selfCOUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or II certified copy thereof(Sec.3800,Lab.Q. Policy No. Company — FOR APPLICANT TO FILL IN Bu1LOING J�,ell ADDRESS nCertified copy is hereby furnished. su.?MR.. s L©D< ® ;� LOCALITY Certified copy is filed with the county building inspectionL� �T YNEAREST department. 0J1 CROSS ST. Date Applicant _ NEAREST ^ �! DISTRICT NO. F,2 UP TYPE P ESSED BY o CROSS ST. /� CON ST.� CERTIFICATE OF EXEMPTION FROM WORKERS' ( LEGAL COMPENSATION INSURANCE i DESCRIPTION LOT NO. BLOCK MAP MIONW AY STATE MAJOR SECOND LOCAL NI OF BLOCS. NO. (CIRCLE) (Tills section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Ily the permit is for one hundred dollars ($100) or less.) USE OF _ '71 SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any personin any manneSEg o w f-b 1 1?6 /� ® c so as to become subject to the Workers Comp ensation Laws. MAIL r OCCUPANCY GROUP Date_ Applicant _ ADDRESS '5'faq ow LES C. NOTICE TO APPLICANT: If,after making this Certificate of CITY (�(l_ NO. 3�7 —9s OCCUPANT LOAD Exemption, you should become subject to the Workere 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. deemed revoked. Panic Devices LICENSED C'ONT'RACTORS DECLARATION OCCUPANCY INSPECTION 1:1 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT[] (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Basi- NO.OF EXITS ness and Professions Code,and my license is in full force an ty nom, PARKING �t effect. ame�cz-_Ulls- PA KIN REQ'D [� PROVIDED I _ 1 License Number Lic. Class — C4' LIMITED TIME USE 1— —! Contractor Date DATE DATE FROM: TOM 1 am exempt from the licensing requirements as I am a INSPECTOR'S licensed architect or a registered professional engineer SIZE OF OF SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. (.- ✓ © STORIES � iness and Professions Code). hq FINAL APPROVAL PRESENT USE OF BUILDING 6 I V c•� Lic.or Reg.No. Date — HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's f�, License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING 1, 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 1 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.). Lender's Name , PROPOSED MAX OCC. Lender's Address—. I certify that I have read this application and state that the PERMIT FEE 25-00 above information is correct.I agree to comply with all County ISSUANCE FEE a ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25-00 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE • � - •n Ilnr 11 1'rrmillr�` Date '