HomeMy Public PortalAbout10553 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 75M444 M I SC E�.LA N E®L1 S APPLICATION
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I hereby affirm that I have a certificate of consent tself CE 875(11-84)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. +.
UILDIN
BG
Policy No. Company FOR APPLICANT TO FILL IN pUILDIN
Certified copy is hereby furnished. BUILDESSING 0� LOCALITY
ADDR
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. �'lllO ' ` ceoss ST.
Date Applicant NEAREST /� �/ ,,s,A /Jtfc�-
0
DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. /'{/ ,a mule /(I� �D� _ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /
COMPENSATION INSURANCE DESCRIPTION LOT NO. / MAP NIGHwwvgTATE MAJOR SECOND LOCAL
NO. (CIRCLE)N . OF BLOCS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of
SIZE OF LOT'7a VA17 EXISTING BLDG. A Ae-��• / /y'f �/o2'a CD
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 S6E/ a.PRi r_ 7Wri s'
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
MAIL A"01-0
/ q� J `, O
Date A lit ADDRESS 161,55—S BLJ01- /T/� Ve
N, W
ppTEL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY-I-AWpGJ� No. ,j'�f' �S OCCUPANT LOAD y
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❑ No Spec. KnowL
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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. fDV/L1�)J vAI PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class 11;2 &9W "'
F/�/ /' LIMITED TIME USE
Contractor Date �• • "T DATE DATE
0 I am exempt from the licensing requirements as I am a
FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF p INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES / SIGNATURE
iness and Professions Code). FINAL APPROVAL Q
Lic.or Reg.No. Date PRESENT USE OF BUILDING j
HOME OWNER-BUILDER DECLARATION ON•LOT AND TING OF EX SBUILDINGS N'• ( os
I Hereby affirm that I am exempt from the Contractor's 3307513.1C.
-
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING i +77.1,7
SPACES PROVIDED
I, as owner of the property, will do the work and t e .�
structure is not intended or offered for sale (Secti n t 1-1!H_ :3 1-30
7044,Business and Professions Code). LL —
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
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.C.). i I __I:I ry
Lender's Name ,i;
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE ®� i LI I A :j 1 i,
I certify that I have read this application and state that the O
above information is correct.I agree to comply with all County ISSUANCE FEE V R-e:,
ordinances and State laws relating to building construction,
and h 'ere autho representatives of this County to enter TOTAL FEE 9
,71
upon tl ove-i n o d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
igna ure Permittee Nate