HomeMy Public PortalAbout10130 OLIVE ST_Miscellaneous__ � 'W0RKERS'C014PENSATION DECLARATION 87r. ,(11-84)��
CE � MISCELLANEOUS APPLICATION
' CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or 'fl
a certified copy thereof(Sec.3800,Lab.Q.
IL Z
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING �� �� J LOCALITY
ADDRESS
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. V CROSS ST.
Date Applicant ARE 5,,.. /� `_1 DISTRICT N OU TYPE PROCESS BY
CROSS ST. Ci� � �D(y ^ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL dQ
/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF SLUGS. /+t
(This Section need not be completed if the work involved TRACT NOW ON LOT C7( USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) us9 OF
SIZE OF LOT f EXISTING BLDG.
I certify that in the performance of the work for which this o
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 , o
Date ADDRESS
Applicant ul
NOTICE TO APPLICANT: If, after making this Certificate of CITY ,Tool. — OCCUPANT LOAD
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 USE GEOLOGY INSPECTION
deemed revoked. No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- No. OF EXITS
ness and Professions Code,and my license is in full force and
effect. I - PARKINGREqD PROVIDED
SPACES o
License Number Lic. Class UQm LIMITED TIME USE
Contractor Date d C/ 7— DATE DATE
OM: To:
I am exempt from the licensing requirements as I am a ' S
licensed architect or a registered professional engineer SIZE OF /j y�/ NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. /g L16 3� / STORIES I SI NATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
�'� i
Lic.or Reg.No. Date
0.9A
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
O O O 030
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi I o - 8 (150
ness and Professions Code): NO. PARKING
=
I, as owner of the property, will do the work and the SPACES PROVIDED &,a,5z, o 0 0 $Q5 Q v
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 10
j.!;, 0.03 $$
�
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 7
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. � �fi o d — B� 4Q4A..U4
Lender's Name
OPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the av
above information is correct.I agree tocomply with all County ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
Ir�the above-mentioned property for inspection purposes.
Z42' /' ��L� 2L'�.}�SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date a