HomeMy Public PortalAbout9563 OLIVE ST_Miscellaneous__ f,
WORK S'COb1PENSA�ION DECLARATION CE 875(11-84) M ISCELLANEOUS APPLICATION
I'7,erelay affirn that•1 have a certificate of consent to self COUNTY OF LOS ANGELES BC
AND SAFETY DIVISION
insure, or a cer irate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.). %�•
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS C/
Certified copy is hereby furnished. BUILDING J
ADDRESS �J ,� / LOCALITY /.
J f
Certified copy is filed with the county building inspection LOCALITY r.)' C NEAREST
, I C� e�� CROSS ST.
department. ,�
Date Applicant cRoss st �C �.f DISTRICT
/NO. 2pup corlsT, CESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS'
LEGA L C. y��/ �JJ( ffi
CIRC(
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP AY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) ^/ USE OF
SIZE OF LOT 3T EXISTING BLDG. �•
I certify that in the performance of the work for which this , �, o
permit is issued, 1 shall not employ any person in any manner OWNER �=
-L t c i
so as to become subject to the Workers' Compensation Laws. MAIL �� h , ^ OCCUPANCY GROUP -3 0
ADDRESS f� '`�� .L l..�i C-I>
Date Applicant w
NOTICE TO APPLICANT: If, after making this Certificate of C.QY� ITVE.� '� OCCUPANT LOAD
Exemption, you should become subject to the Workers' We-
Compensation provisions of the Labor Code,you must forth- APPLIC TION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
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 and - I�1
effect. .. 7 SPACESPARKINREq'D I PROVIDED
License Number Lic. Class p ��" J
f LIMITED TIME USE
Contractor Date ri! �JU DAT[ DATA
L FROM: TO:
El I am exempt from the licensing requirements as I am a ' _Vr z e '444'e_.
licensed architect or a registered professional engineer SIZE OF NO.OF IN
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES SI NATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL g� �2 /1F� /
Lic.or Reg.No. _
Date (L' 7 "(�
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 30
ON LOT AND USE A44T°4
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- 3303 242°70
ness and Professions Code): NO. PARKING 1 IT��fi
I I, as owner of the property, will do the work and the
SPACES PROVIDED S
structure is not intended or offered for sale (Section TOTAL 242-70
7044,Business and Professions Code).
PROPOSED USE OF BUILDING CHECK 242°70
CONSTRUCTION LENDING AGENCY
CHANGE °00
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 0000-0001 11/ 1/95
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE 5 0 3096 1 AM 9:50
I certify that 1 Have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE a 7. 3 0
ordinances and State laws relating to building construction,
�96K
by authorize representatives of this County to enter TOTAL FEFy 7 D
above-me Zoned pro for inspectio purposes.
I e, ` / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee ate