HomeMy Public PortalAbout9053 OLIVE ST_Miscellaneous__ WOR01 KERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION
I heseb,&affh n that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, dr a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
FICertified copy is hereby furnished. BUILDING �� I
ADDRESS LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY �i NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTI�.L�T}�O. G UP TYPE PROCES ED BY
CROSS ST. ,��,/// /) �% CONST I
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ,n �� (((F%
COMPENSATION INSURANCE DESCRIPTION LOT NO. (�y BLOCK MAP �I,y f f"AY STATE MAJOR SE CON OCAL
3a39Z NO. I (� CIROLE)
NO. OF BLDGS.
(T111S SCCtIOn 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 �q
SIZE OF LOT EXISTING BLDG. (� d
I certify that in the performance of the work for which this e
permit is issued, I shall not employ any person in any manner OwNE y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 0
ADDRESS JP
�d/� V
Date Applicant l TEL.? / OCCUPANT LOAD W
NOTICE TO APPLICANT: If, after making this Certificate of clrY �7"C No, d0 O_
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. Know].
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 andj
effect. '� SPA PACES
REq'D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date U' 1�!7 Chi�'G7lr / � DATE DATE
El I am exempt from the licensing requirements as I am a '
FROM: TO:
licensed architect oI a registered professional engineer SIZE OF Q NO.OF INSPECTOR
NATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 9 2 8 A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's # D D D o 3 Q
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED I o o80,50
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section o 80,5030:
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 0328-88
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
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE Oe
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for spection pure s
/ y. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date