HomeMy Public PortalAbout9090 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION
I laffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insureure,, o or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN pOUILDING
DDRE53 ��
Certified copy is hereby furnished. BUILDING 9D 0 Q, ' / LOCALITY ? �'/
ADDRESSJeV
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. ceoss ST.
YPE ROCESSED BY
Date Applicant NEAREST DISTRICT O. GROUP CONST.
CROSS �.r
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /� /� L
COMPENSATION INSURANCE DESCRIPTION LOT NO.,Jd BLOCK MAP HIGHWAY(CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS. NO.
(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.) SIZE OF LOT EXISTINuSE OF
G BLDG ti
I certify that in the performance of the work for which this o
permit is issued,I shall not employ any person in any manner OWNER v
so as to become subject to the Workers' Compensation L� OCCUPANCY,GROUP o
MAIL
Date'Z- �Applican ADDRESS / �rQ7 OVS117LE t;
v
' TEL. �/� �/ OCCUPANT LOAD y
NOTICE TO APPLICANT: If after mak' th Ce ITY No. G/C l
Exemption, you should become subject to the o z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 91 Panic Devices El
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
effect. PARKING REQ'D PROVIDED
- SPACES
License Number Lic. Class rv— 4 X LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sl NATURE
iness and Professions Code).
FINAL APPROVAL
PRESENT USE OF BUILDING yy
Lic.or Reg.No. Date— (!.J
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE s 0 3 4,4 A
I hereby affirm that I am exempt from the Contractor's /J ,
License Law for the following reason (Section 7031.5, Busi- fC # D o D o 3 0
ness and Professions Code): NO. PARKING /�
I, as owner of the property, will do the work and the
SPACES PROVIDED 1 l!
0 0 8 5 O
104 structure is not intended or offered for sale (Section o -'o 8 0,5 0 c=J
7044,Business and Professions Code). oo -
PROPOSED USE OF BUILDING PK P O Q O 8 8
CONSTRUCTION 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.C.).
Lender's Name
PERMIT FEE �
PROPOSED MAX. OCG.
Lender's Address -
I certify that I have 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
upon the above-mentioned property for inspection purposes. SEE FEVERSE FOR EXPLANATORY LANGUAGE
Signature of rmit ee Date
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