HomeMy Public PortalAbout9449 OLIVE ST_Miscellaneous__ WORKERS'I�ORiPENSATION DECLARATION CE 875(2-80) W SC E LL A N EO LIS APPLICATION
I II;^eby affirm that I have a certificate of consent to 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.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING /y� I
ADDRESS /*q 9
El D I✓e• ���
Certified copy is hereby furnished. BUILDING (, /�/ r--• UP `,'V� S_l LOCALITY
ADDRESS T'� 7 r
Certified copy is filed with file county building inspection NEAREST t�
department. LOCALITY C• CROSS ST. I-10
1
Date Applicant NEAREST ,p DISTRICT N G OUP TYP PROC SED BY
CROS5 ST. Glover
CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL QIp
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SE ND LOCAL
NO. OF BLDGS. IL
(This SO need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
perm
by the permit is for one hundred dollars ($100) or less.) �/ EXISTING BLDG.
USE of
SIZE OF LOT (oD < oO {j V
�D /
1 certify that in the performance of the work for which this �
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. /��/ t S LA C OCCUPANCY GROUP - �j W
MAIL
ADDRESS `�/7 1 ,4 f 9 �. 0 1 ,V� .�/
I• a
Date Applicant _ I _ to
/^� . TEL. p
NOTICE TO APPLICANT: If, after making this Certificate of CITY I em to c 0— 8 1 7 No. � iZ0 S'S`9D OCCUPANT LOAD
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 $ ❑
deemed revoked. Cl No Spec. KnOWi. ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION01 Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT L--1 (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
effect. 00 Ro d rill PARKING-
License Number Lic.Class FAQ f!t0 Q re — E SPACES
• REO'D E= PROVIDED
S CZ LIMITED TIME USE
Contractor . Date DATE OATS
OFROM: TO:
I am exempt from the licensing requirements as I am a.
licensed architect or a registered professional engineer SIZE OFNO. OF INSP CTOR'S
acting In my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES 5 NATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL �—
Lic.or Reg.No. Date P�7 C C
HOME OWNER-BUILDER DECLARATION NO.OF EZA
XISTING BUILDINGS G /
ON LOT AND USE G0
I hereb O Q0
0
y�,affirm that 1 am exempt from file Contractor's I G o 8
License Law for the following reason (Section 7031.5, Busi- o o o 8 a 5 Q cii
ness and Professions Code): No. PARKING
SPACES PROVIDED O 7 2 9 b O CJ 7
I, as owner of the property, will do the work and the � / G 7
structure is not intended or offered for sale (Section
7044,Business and Professions Code). PROPOSED USE of BUILDING
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
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
1 1 ertif) that I hale 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, TOTAL FEE O _�
and leer authorize representativ f this County to enter
on above-mentione oper y for inspecti purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
101W a ;ll
Signature of Permittee Date