HomeMy Public PortalAbout10650 OLIVE ST_Miscellaneous__ WORKERS'COfa1PENSATIONDECLARATION CE 875(11-84) 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.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRE55 `
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C�
Certified copy is hereby furnished. BIL
UDING Lam,
ADDRESS LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY I NEAREST
department. y 0 ceosS ST.
Date Applicant NEARESTDISTRICT NO,
GROUP TYPE ' P CESSED BY
CROSS ST. L CONS /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
OF SLOGS.
Ne. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS NO_
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 0
permit is issued, I shall not employ any person in any manner OWNER — G-` AMC 5-Dso as to become subject to the Workers' Compensation Laws. MAIL /016,q—
Date
OCCUPANCY GROUP o
f
ADDRESS 0 0 V
Date Applicant 0-
NOTICE TO APPLICANT: If, after making this Certificate of CITY J [� NOL�/8 Vp/-O '
AOCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: z
Compensation provisions of the Labor Code,you must forth
with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ 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 / n
effect. G� /'s PARKING REWD PROVIDED
SPACES
License Number Lic. Class
_ LIMITED TIME USE
Contractor Date �� �; DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. F PROM: To: INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �3 STORIOES l SIGN URE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING Q
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTINGBUILDINGS
ON LOT AND USE ACCT.
I hereby affirm that I am exempt from the Contractor's _a_'
License Law for the following reason (Section 7031.5, Busi- Ll�; y 219.75,
ness and Professions Code): NO. PARKING
�Ellj
I, as owner of the property, will do the work and the SPACES PROVIDED 1
structure is not intended or offered for sale (SectionT+ATL 219 -75
a.
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 219.75
I hereby affirm that there is a construction lending agency CHANGE .013
for the performance of the work for which this permit is
issued(Sec.3097,
Lender's Name 0000-0001 1/1 '/93
PROPOSED MAX. OCC.
Lender's Addres ` t 7
I certify that I have read this application and state that the PEr3MlT FEE / dam 1 ��11y�,1�
above information is correct.I agree to comply with all County ISSUANCE FEE 75—
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter L-ITAIF.1
upon tl ab ve-mentioned property for inspection purposes.
_
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature V Permitted Date