HomeMy Public PortalAbout10412 OLIVE ST_Miscellaneous__ �r WORKERS'COMPENSATION DECLARATION CE a75(11-84) MISCELLANEOUS APPLICATION hareaLs�m that I have a certificate of consent t self
insure,, qS a certificate of Workers'Compensation Insurance,
e,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS P 41
y
Certified copy is hereby furnished. BUILDING - LOCALITY
ADDRESS l (,?bve 3"T•
FICertified copy is filed with the county building inspection LOCALITY wk a cRoss sT.
department.
Date Applicant NEAREST DISTRICT G YPE PR C SSED BY
CROSS ST. G CO T
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR CON- LOCAL
OF HLD 6NO. (CIRCLE)
NO. 3.
(This section need not be completed if the work involved TRACT 1bS6_, NOW ON LOTI - f_
USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT S y /3 ' EXISTING BLDG.
I certify that in the performance of the work for which this /A9 " o
permit is issued, I shall not employ any person in any mannerOWNER =
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP i o
Date Applicant ADDRESS Jb�/2 bLW/E 5 L"NOTICE TO APPLICANT: If, after making this Certificate of CITY nj C4 NOL a 69 °.C. 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 oIlthls permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIPanic Devices
ON
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. C / PARKING RMQ'D PROVIDED
- SPACES 1�
License Number Lic. Classr vfJ Ods S
LIMITED TIME USE
Contractor Date 470,0 9t 'L� Z DATE DATE
FROM: TOI
❑ I am exempt from the licensing requirements as I am a 4voc.
licensed architect or a registered professional engineer SIZE OF NO.OF INSP• CTO R'S
g P SI NATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code). FINAL APPROVAL ,� A
Lic.or Reg.No. Date
PRESENT USE OF BUILDING
L �C�
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS /
ON LOT AND USE ;98920A
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- # 0 0 0 0 30
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED ') 0 - 8(150
structure is not intended or offered for sale (Section
7044,Business and Professions Code). o c c $Q 5 053
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 0 2 0 7—E 8
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
PROPOSED MAX. OCC.
Lender's Address J`Q
PERMIT FEE lJ
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 SU
ordinances and State laws relating to building construction, r, S
and hereby authorize representatives of'this County to enter TOTAL FEE (�
upon the above-mentioned rop y fqr inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermittee Date