HomeMy Public PortalAbout9836 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION 1?. CL�4RATION 76M444
,. CE 875 (11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING �7 / LOCALITY -
ADDRESS �J
0 Certified department. A Py is filed with the county building inspection LOCALITY ��LC/1—Y CA. NEAREST
� r CROSS ST.
Date Applicant NEAREST // ��7')y/{/ DISTRIC NO, RfJ��uP TYPE / 1PRO!�-DBY
pp CROSS ST. '� L-JlL�/V �� L�I�v �D1 CONST,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VVV
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 7 MAP HIGHWAY STATE MAJOR SEC D LOCAL
_ NO. (CIRCLQ)
+��G, NO. OF BLDGS.
(This SCCtIOn need not be completed if the WOIk IRVO1Ved TRACT ��'/V NOW ON LOT 2 US ZONEF
AL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 'y // USE OF v
SIZE OF LOT /V/D$ EXISTING BLDG.
I certify that in the performance of the work for which this _
0
permit is issued,I shallnot employ any person in any manner OWNER V,41_� �f��b UL u�itZ v
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPMAIL
—
ADDRESS ��� L 57 U
Date Applicant !/ I„
NOTICE TO APPLICANT: If,after making this Certificate of CITY � �f�7�� G'l�`
T.L. OCCUPANT LOAD y
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
With comply With such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ E] No Spec. Knowl.
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 �/
effect. .�/V-��� L PARKING REq'D PROVIDED
_ SPACES
License Number Lic. Class �FT ��y
AIA POM: LIMITED TIME USE
Contractor Date DATE[ TO: OA TQ
I
DI am exempt from the licensing requirements as I am a F1,V�J�. / ,1 r grf,0 �.3
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL _��
PRESENT USE OR BUILDING /G
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS-0.
UILDINGS 9 4 5 3
ON LOT AND USE J IL
I hereby affirm that I am exempt from the Contractor's # 0 0 0 0 3 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED C D
8(150
❑ I, as owner of the property, will do lite work and the 00080,505)
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
425-88
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
0
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 7 I
I certify that I have read this applica ' an a that the
above infor correct.I agree comp vi h all County ISSUANCE FEE
ordinan and Stat laws relat' to b 'ding nstruction,
and r by autho ' e repre tives this Co ty to enter TOTAL FEE
up th abov ention rty f i sp n purposes.
�l SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of rt
Mime Date d