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Home My Public Portal About10661 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11.84) MISCELLANEOUS AP P U C AT I O N • CE 875 1 ilt+ieby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION blsure, or a certificate of Workers'Compensation Insurance,or I a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. r' -}i ADIL-DIN LOCALITY Certified copy is filed with the county building inspectioyny Lor.A ��Tr NEAREST department. � -� 7 cROss ST. Date Applicant NEAREST DISTRICT NO. [GROUP TYPE CESSED BY Pp CROSS ST. + CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF 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.) USE OF SIZE OF LOT EXISTING BLDG. Jl� >•- I certify that in the performance of the work for which this ci permit is issued, I shall not employ any person in any mannes—cg Dvun—tof building �J s<I as to become subject to the Workers'Compensation Laws---- OCCUPANCY GROUP °= MAIL-- n_ ADDRESS r Date Applicant -� L= �• w 0. NOTICE TO APPLICANT: If,after making this Certificate of CITY TC L C� NOL ,�� OCCUPANT LOAD Exemption, you should become subject to the Workers' gppLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you mast forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION 11PC ❑ No Spec. Knowl. deemed revoked. LICENSED CON'('RACI'ORS DECLARATION oecurwNer INSPECTION❑ Panic Devices I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code,and my license is in fill force a effect. .Name .•of business PARKING REG,D 1 1 PROVIDED1 SPACES 11JJ JJ License Number _--- Lic. Class — � LIMITED TIME USE Contractor Date DATE DATE FROMS TO: ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE of NO.OF I SIGNspr. TOR licensed in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL Lic.or Reg.No. Date PRESENT SE OF BUILDING `4 Z- - HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE �'�' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCI'ION LENDING AGENCY PROPOSED USB OF BUILDING 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 Lender's Name — PROPOSED MAX.OCC. IJ T.. Lender's Address _ ' 1 certify that 1 have read this application and state that the PERMIT FEE 251.00 above information is correct.1• e t comply with ounty ISSUANCE FEE ordinances and State laws o building struction, 25 00 =i •y and hereb author' rep ' es of this unty to enter TOTAL FEE upon t11 uv - tfo fly for' ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX- - _ J I, i 1 WORKERS'COl[PENSATIONDECLARATION CE 875(11-84) MiISCELLANEOUS APPLICATION I I hereby-affirm that I have a certificate of consent to,self COUNTY OF LOS ANGELES BUTLDIIVG AND Sr1FETY D TSIOAI Insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). ILDI . ALJ I Policy No. Company FOR APPLICANT TO FILL IN A RESS Certified copy is hereby furnished. BUILDING ; LOCALITY % ADDRESS { i F Certified copy is filed with the county building inspection % LOCALITY � �� NEAREST CROSS ST. � department. / Date Applicant NEAREST DISTRI T NO ITYPIC CONS/ SSED BY • CROSS ST. (I i CERTIFICATE OF EXEMPTION FROM WORKERS' DESLEGAL CRIPTION LOT NO. BLOCK MAP HIGHWAY COMPENSATION INSURANCE No. (CIRCLE) STATE MAJOR SECOND LOCAL �I NO. OF 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 (SI00) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this _ permit is issued. I shall not employ any person in any manner % OWNER so as to become subject to the Workers' Compensation Laws. % MAIL OCCUPANCY GROUP — ADDRESS _ Date Applicant % TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY OCCUPANT LOAD Exemption, you should become subject to the WorkersAPPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- ) with comply with such provisions or this permit shall be TRAILER USE (l GEOLOGY INSPECTION p No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I airi licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW) i 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 SPACES REG•o PROVIDED H License Number Lic. Class LIMITED TIME USE U, Contractor Date DATE DATE W PROM. TO: 0 I am exempt from *lie licensing requirements as I am a INSPECTOR'S licensed architect or a re=istered professional en.-ineer SIZE OF NO.OF SIGNATURE Z acting in my professional capacity 1Section 7051. Bus- EXISTING BLDG. STORIES 9 iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING U Lic.or Reg.No. Date YYYY is I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS "►1 �� L' ON LOT AND USE I hereby affirm that i am exempt from the Contractor's /J-�' 01000-0001 911.9,!91 I License Law for the following reason (Section 7031.5. Busi- ness and Professions Code): NO. PARKING ,}G c SPACES PROVIDED �t'295 1 AMIGeP�i'�L' I, as owner of the property. will do the work and the structure is not intended or offered for sale +Section 1 7044.Business and Professions Code). I % PROPOSED USE OF BUILDING �A.✓` � CONSTRICTION 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.Q. Lender's Name Lender's Address PROPOSED MAX. OCC. 25.00 ) � PERMIT FEE I certify that I !rave read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 upon the above- entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE % % r 1 ' 1 attire of P"nn ttee Date