HomeMy Public PortalAbout9070 OLIVE ST_Miscellaneous__ WOR4ERS'�COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby•afflim that I have a certificate of consent to self
insuf6, ora certificate of workers'Compensation insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LI
acertified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL INBUILDING
ADDRESS `.�IJe, Gtve QA
Certified copy is hereby furnished. wooeess D , LOCALITY AAAI
Certified copy is filed with the county building inspection LOCALITY1 ` NEAREST
department. /e e-I'*
CROSS ST. �lJ I GvV�pL
Date Applicant NEAREST DISTRICT NO. GROUP TYPE PRO D BY
CROSS ST. 0 (z 2 CONST.'�gl�/^
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (JU J -VI- '
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK t MAP HIGHWAY NO. (CIRCLE) STATE MA10 SE CO CAL
NO. OF BLDGS. fnel
(This section need not be completed if the work involved TRACT NOW ON LOT �I//�x�R E ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) rp USE of W-1 O}..
X
SIZE OF LOT �0 EXISTING BLDG.
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 owNER 2 _ e_/7
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
r
Date ADDRESS O Applicant 0 011,11e LULL
NOTICE TO APPLICANT: If, after making this Certificate of CITY 2 ' NO. OCCUPANT LOAD
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth- APPLICA ION FOR EXIT HARDWARE:
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 ITE s BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- No, of Exlrs
ness and Professions Code,and my license is in full force and Y
effect. Y ^/� SPACES G REQ'O PROVIDED
License Number Lic. Class1-E LeutRrlr ,011•t
_y� LIMITED TIME USE
Contractor Date A t aim' •V qJ-PDATE GATE
El I am exempt from the licensing requirements as I am a
FROM: TO:
licensed architect or a registered professional engineer IZE OF NO. OF IN SPE CIO R'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 141A, SIGNATURE
iness and Professions Code). I � `l
PRESENT USE OF BUILDING FINAL APPROVAL 19;r(l-12
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS N 9.L• 006
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
F1I, 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 -
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 -
PERMIT FEE .�
I certify that I have read this application and state that the 19
above information is correct.I agree to comply with all County ISSUANCE FEE ,75 -
ordinances and State laws relating to building construction, j• J
hereby authorize representatives of this County to enter TOTAL FEE - - -See- ��CG �
n the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
u 6a —40d" Z444
atur
Signe of Per ittee I Date