HomeMy Public PortalAbout10237 OLIVE ST_Miscellaneous__ WORKERS', COMPENSATION DECLARATION'. ,�5M44875 i4(1'1-84) M.ISCELLANEOUSAPPLICATION .
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nsur , o affirm. idat I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND-SAFETY,DIVISION '
insure, or a•certificate'of Workers'Compensation Insurance,!or "•.,�'
a certified copy;thereof(Sec,3800,Lab.C.). I: -
Policy'No. Company ADRR TNG
FOR ARPLIC'ANT•f0 FILL IN nDUREss
❑ Certified copy.is.'hereby furnished.
ADDRESS
❑ Certified copy is filed,with the county buildmg•inspection.. LOCALITY NEREST
department. ' OC _2 . �% ACROSS ST.
Date
Applicant NBAREST DISTRIC NO�y GRAUP TYPE CESSED HY
CROSS ST. n Q /i CONST,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 7 O V
COMPENSATION INSURANCE DESCRIPTION LOT NO. /. BLOCK MAP' HIGH*Av NO. (CIRCLET STATE MAJOR SECOND LOCAL '
' '
No.,OF BLDGS.
,(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 ($1'00) or less.) USE OF
SIZE OF LOT1-2y/Z,0 EXISTING BLDG. ,:r „, , �••
I certify that in the perforrriance of the work for which this o
permit is issued,,I.shall not employ any person in any manner OWNER51>
,'•so'as to,become,subject to the Workers' Compensation Laws. MAIL L5� OCCUPANCY GROUP
ADDRESS - O
'Date`-• " Applicant .5'dm� 4'S- 6 our cFs
TEL. W
NOTICE.TO'-APPLICANT: If, after making this Certificate of CITY NO. -OCCUPANT LOAD y
Exemption,'''-ydu should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: _
with comply with such 'provisions or this permit shall be TRAILER USEE
GOLOGY INSPECTION
❑ E] No Spec. Knowl.
deemed revoked..',; ❑'
LICENSED CONTRACTORS DECLARATION 'OCCUPANCY.INsPECTION❑ Panic Devices
I hereby affirrn,that I"am-licensed PERMIT
nsed Under proVisions: ❑ ( MBof Chapter � � LIST ITS IIS ELOW
9 '(coirirneiicing with S'ect'ion 7000) of Division 3.of the Busi- No, oF'EXITs '
ness and Professions Code,and my license is in fu.11 force and, , �7 -�y-y '
effect. -V/J yW CEZ) �!/ /C/�L7 PARKING
SPACES R D 'PROV.IDED O
License Number Lic. Class P87eOn?T e01LA1C?Z7&Z) LIMITED TIME USE
L ��
Contraetol Date DATE DATE
❑ I ek6mpt•from the licensing requirements as I am a
am" FROM: T°`'
licensed architect ora registered' professional engineer SIZE OF NO.OF INSPx&rOR'.S
'acting-in,my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
inessandProfessions Code). FINAL APPROVAL 1-7 / � ,i`
Lic.Or Reg.No. Date ' ' PRESENT USE OF BUILDING .• �!�
Ce
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ;
ON LOT ANI '
I.hereby' affirm that I am ekempt from'the Contractor's
License Law for the.following.reason (Section 7031.5, Busi-
ness and Professions,Code)•. No: PARKING `Jt
SPACES PROVIDED
I; as'owner• of the property, will do the.work and"the i* `TE.
structure is.not 'intended or offered for'sale (Section
'�'`
7044,Business and Professions Code). Via ; =L
• .�. •'fie-
PROPOSED USE OF BUILDING
•CONSTRUCTION LENDING AGENCY CHOCK I
I hereby affirm that there is a construction lending agency i:13 h�; - !'
.for the performance of the work for which. this permit is --
issued'(Sec.3097,Civ.Q.
Lender's Name
+ PROPOSED MAX. OCC. � s:jeti ! rSr t fry
U-= ;
Lender's Address �=
' PERMIT FEE
I certify that I have read this application and state that the =c05 E AM 0I:'5[
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
upon above-mentioned property for inspection purposes. i
SEE REVERSE FOR EXPLANATORY LANGUAGE
4Z
Dat
Signature of Permittee