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Home My Public Portal About9011 OLIVE ST_Miscellaneous__ J WORKERS'COMPENSATION DECLARATION 176aaaaa M I SC E L LA N E O lJ S A P P L I C A T I O N CE 875 (11-84) I I hereby as certirm that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN ADBu1LDINGDRESS 20 — C. Certified copy is hereby furnished. V BUILDING fl_ ©L/vim LOCALITY DDRESS ❑ Certified copy is filed with the county building inspection W L CALITY NEAREST department. TE el Cl C•� 9 CRosS ST. Date Applicant NEAREST �+ �/� II�� `�., DISTRICT NO. GROUP TYPE P OC SEED BY CROSS ST. QS G !E�Y � A CAST' f CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP �//� HIOHW AY NO. /Y'—�(yj(eliiel.$) STATE MAJOR SECOND IOAL INC). 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 I certify that in the performance of the work for which this IZE OF LOT EXISTING BLDG. �3 COt D 0 permit is issued,I shall not employ any person in any manner OWNER Feq y/e U orf JeEj s lOry -&F O&. S' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY•GROUP .EE] o Date Applicant DDRESS 5,(/02_ �rJSE/7C$1� [v �- //,�TEL.A r� LV NOTICE TO APPLICANT: If, after making this Certificate of CITY (Y/J/jip/EC C�NO d 5 6_951 OCCUPANT LOAD Exemption,.-you should become subject to the Workers' Compe sation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with omply with such provisions oI this permit•shall be TRAILER USE ❑ GEOLOGY INSPECTION El Spec. Knowl, deem,d revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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 I� effect. PARKING REQ D D PROVIDED �- 1 SPACES JJ License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer ZE OF NO. OP FROM: To: INSPECTOR s acting in my professional capacity (Section 7051, Bus XISTING BLDG. STORIES SI NATURE iness and Professions Code). �+� FINAL APPROVAL. PRESENT USE OF BUILDING Lic.or Reg.No. Date 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 I, 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING G� 5 4 4,5'A I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is # 0 0 0 0 8 8 issued(Sec. 3097,Civ.Q. 0 0 0 0 0 0 o M C.) Lender's Name PROPOSED MAX. OCC. Lender's Address "` 0 9. 1 6-$6 I certify that 1 have read thi pplication and state that the PERMIT FEE above information is correct. _gr to comply with all County ISSUANCE FEE ordina ces nd Sta laws la ' to building construction, and a author' repr en ves of is County to enter TOTAL FEE n above--m t' e p y for in pection purposes. SEE-REVERSE FOR EXPLANATORY LANGUAGE �v Signature of Permit a Date