Loading...
HomeMy Public PortalAbout10531 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATI®N I Sheri ! affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 4uyc;'or-1 certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. - Company FOR APPLICANT TO FILL IN BUILDING lO 3, Bi �7— ADORESS ❑ Certified copy is hereby furnished. BUILDING /0 6 © •q^ LOCALITY � 1 C'A • S r-1Certified 1, Certified copy is filed with the county building inspection ADORE NEAREST department. LOCALIT � J e CROSS ST. Date Applicant NEAREST l/ DI1rICT NO. GROUP TYPE ��// PROCESS D BY CROSS ST. hI 1• CON aT.�}J�/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /J ��� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP �y��f (e R.L.) STATE MAJOR SECOND LOCAL a. (This section need not be completed if the work involved NO. OR BLDGS.�� O l+ p TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) Q/� USE OF �r�1 V SIZE OF LOT Z I�0 EXISTING BLDG , I certify that in the performance of the work for which this //ll ((( O permit is issued, I shall not employ any person in any manner OWNER C J. U.,V3 I— so as to become subject to the Workers' Compensation Laws. wMAIL , OCCUPANCY GROUP C.1 LU ADDRESSU Date Applicant 52 �J NOTICE TO APPLICANT: If, after making this Certificateof cITY`� No. ! �G'�7$� 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION 13 No Spec. Knowl. ❑ deemed revoked. I _ OCCUPANCY INSPECTION Panic Devices ElLICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter • SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and FC ra '� all PARKING: effect. REQ'D O PROVIDED �+ SPACES License Number Lic.Classy LIMITED TIME USE Contractor &; 1-0 ate r S 3 ' 0.4 NA U!5 � DATE DATE . PROM: TO: I am exempt from the licensing requirements as I am a, licensed architect or a registered professional engineer SIZE OF / / NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. e— STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING MA C FINAL APPROVAL Lic.or Reg.No. Date EXISING HOME OWNER-BUILDER DECLARATION ON LOT AND USE ND,OF AND USE BUILDINGS i I hereby affirm that-I am exempt from the Contractor's; ! Qy�9 2 w License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section, 7044,Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY ,4 5 2 8 E I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 4' o e a o 30 issued(Sec. 3097,Civ.C.). v , Lender's Name PROPOSED MAX. OCC. D o 80 5 0 Lender's Address PERMIT FEE �� 'on c � I certify that I have read this application and state that the sf ' i ISSUANCE FEE !� above information is correct.I agree to comply with all County' � ordinances and State laws relating to building construction, 16-83 TOTAL FEE and hereby authorize represent .ves of this County to enter upo the above-mentioned pr rty for inspection purposes. SEE REVERSE F01W EXPLANATORY LANGUAGE Ignature of Permittee Date