HomeMy Public PortalAbout10215 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 1 76M444 1
I CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of workers'Compensation insurance,or ( COUNTY OF LOS ANGELES' BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company 1 FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDINGO 2 IS
ADDRESS L•I t) LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GR9UPTYP P CESSED HY
CROSS ST. �' Q 3 5T.
CERTIFICATE OF EXEMPTION FROM WORKERS' - d
COMPENSATION INSURANCE t DESCRIPTION LOT NO. �3 BLOCK MAP I HIGHWAY STATEIV
MAJOR SECOND LOCAL
NO. I• (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT '' 43 q- NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
1 SIZE OF LOT EXISTING BLDG. I '
I certify that in.the performance of the work for which this CD
permit is issued,I shall not employ any person in any mannerI OWNER �j -�'prJ
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS • r•"
Date Applicant + LI V LLI
cLI
NOTICE TO APPLICANT: If,after making this Certificate of CITY_eMQLe_C_i-6 NOL U43—L[0,35 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code,you must forth
with coni with such provisions or this permit shall be E]
deemed revoked. p p TRAILER USE ❑ GEOLOGY INSPECTION❑ I NO Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
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 NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. / PARKING REQ,b = PROVIDED
SPACES JJ
License Number Lic. Class LIMITED TIME USE
1
Contractor Date I DATE DATE
❑ I am exempt from the licensing requirements as I am a PROM? TOC
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
. FINAL APPROVAL.
LIC.OI Reg.NO. Date PRESENT US OF BUILDING i 16-1
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 1
License Law for the following reason (Section 7031.5, Busi-
3303 ? 7°7t1
ness and Professions Code): No. PARKING j ,.
SPACES PROVIDED 1 WINS'"
El I, as owner of the property,-will do the work and the
structure is not intended or offered for sale (Section - TOTAL ' 21'27 -70
7044,Business and Professions Code).
PROPOSE lr
USE OF BUILDING I CHECK 227.(l
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency CHANGE °0=1
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. 0000-13001 �� �f��
Lender's Name
PROPOSED MAX. OCC,
Lender's Address OPERMIT FEE 0119 1 • AM 7 0-27.
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE5
ordinances and State laws relating to building construction, n
and hereby a ize representatives of this County to enter TOTAL FEE Z- ,r7D.
upon the a o e-I ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit a Date
• I