HomeMy Public PortalAbout9404 OLIVE ST_Miscellaneous__ WO.PVK]IFS?COMP;j1SATION DECLARATION CE 876(2-80) I� 8�C�LLA N�O U S APPLICATION
1 n�Ieby affthat 1 have certificate of consent scot COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate-of Workers'Compensation Insurance,
e,or
a certified cop) thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANTP FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING LOCALITY
❑ ADDRESS
Certified copy is filed with the county building inspection NCAREST
department. LOCALITY CROSS ST. AA
Date Applicant NEAREST DISTRICT NO. G -UP TYPE PROCE D Y
CROSS ST. ,1 /�(/ 2 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL lJ`(Jo �J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. OF BLDGS. MAP HIGHWAY >.
No. (CIRCLE) STATE MAJOR SEC D LOCAL CL(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS OV
by the permit is for one hundred dollars (S100) or less.) US OF
SIZE OF LOT EXISTING BLDG. cc
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 U
so as to become subject to the Workers' Compdnsation Laws. MAIL OCCUPANCY GROUP W
ADDRESS d
Date Applicant rA
NOTICE TO APPLICANT: If, after making this Certificate of CITY
No
OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATI N FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply With such provisions or this permit %hall be TRAILER USE❑ GEOLOGY INSPECTION C] 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 Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and ��
PARKING
effect. SPACES REQ'D E= PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a. FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie: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 J2 6 7 1.3 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKING
0 0 0 0 3 0
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the I - - 8(150 0 8 a 5 0
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING o 0 0 8 Q 5 050
CONSTRUCTION LENDING AGENCY 03,2.0-87
I hereby affirm that there is a construction lending agency
for the performance of the work for HJtich this permit is
issued(Sec.3097,Civ.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
Aabovei
I h ve ea this application and state that the
do is or ect.I gree to comply with all County ISSUANCEFEE
d e ws lating to building construction, TOTAL FEE rite epr entatives of this Coun to enterv -I I property for ins si pu os SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date