HomeMy Public PortalAbout10321 OLIVE ST_Miscellaneous__ • WORKERS'COMPENSATION DECLARATION CE 875 0 1-84) 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING •�� /
ADDRESS
Certified copy is hereby furnished. BUILDING � / LOCALITY `
ADDRESS O
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. C ROSS ST.
Date Applicant NEAREST G DISTRICT O. GR UP TYPfi ::!;EjPROCESSED BY
CROSS ST. •�+ �. Ile
• �!t �� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �
COMPENSATION INSURANCE OESCRIPTIO4 LOT NO. ,j5 BLOCK MOP (CCR CLC) STATE MAJOR SECOND LOCAL
HWAY
NO. OR 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 ($100) or less.) 2 USE OF
SIZE OF LOT 7CXI03 EXISTING BLDG. 4 }
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 S"i
90 as to become subject to the W rkers' Comp sation Laws. MAIL OCCUPANCY GROUP o
ADDRESS �'SO A _ V
Date-I'12§0Applicant w
EL. Jj 7S_J' COJ D_
NOTICE TO APPLICANT: If,afte mak' this Certificate of CITY , �t NO. �a ��{ OCCUPANT LOAD
Exemption, you should become subj 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.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION)a 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'D SPACES PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date FROM: DATE O: GATE
r
OR'S
D I am exempt from the licensing requirements as I am a C.
licensed architect or a registered professional engineer SIZE OF o,je- NO. OF INSPECT
TURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �' .+QJ STORIES SIG A
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date !J/ Imo
01
HOME OWNER-BUILDER DECLARATION NO. OFAXISTING BUI D s
ON LOT ND USE
I hereby affirm that I am exempt from the Contractor's IS
License Law for the following reason (Section 7031.5, Busi- o �
ness and Professions Code): NO. PARKING
SPACES PROV ID EO
1, as owner of the property, will do the work and the OEC
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 4 Lk/v6•_
for the performance of the work for which this permit is -i
issued(Sec.3097,Civ.Q.
Lender's Name 0p „J
PROPOS• D AX. O
Lender's Address 'tE
1 certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, QQ
and hereby authorize representatives of this County to enter TOTAL FEE e
f u on the above-mentioned property for inspection purposes.
p. SEE REVERSE FOR EXPLANATORYIAGE ca
� '17-0
1 Sign re of Permittee Date a o