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Home My Public Portal About9856 OLIVE ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8754(11-84) MISCELLANEOUS APPLICATION I hereby a' in tH t I have a certificate of consent to self insure, or a 41tificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �J a certified coby thereof(Sec.3800,Lab.Q. `Poll No. �-Company BUILDING 'Policy P FOR APPLICANT TO FILL IN ADDRESS a Certified co is hereby furnished. BUILDING 86 0�1.V[� ��' Py y ADDRESS LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. Te" P1_ � G T ceoss sT. Date Applicant NEAREST Dcwoss sr. IS, ICT No. pvjl—y 3 corosr. T PE O D BY CERTIFICATE,OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP IDHWAY STATE MAJOR SECOND LOCAL NO. CIRCLE) No. OF BLOGS. (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.) rsD q us r. of 4 ,'S V I certify SIZE OP LOT EXISTING BLDG,that in the performance of the work for which this o pe It is issued,I shall not employ any person in any manner OWNER v 9 �-¢ aW � s' as to become subject to the W/forkers' Co/m7pensation Laws. MAIL t _ •OCCUPANCY GROUP �.3 0 3 F 1•(1 ia� _ ADDRESS J� O �� .• F V PP .r'�T.� e� t A licant TEL. u.l NOTI TO APPLICANT: If, after making this Certificate of CITY r No OCCUPANT LOAD f (fl(ost'S z Exemption, you should become subject to the Workers' -- Compensation provisions of the Labor Code,you must forth- APPL CATION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. ElPanic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 AA),, a , effect. Ae WPARKING REQ'D PROVIDED' I SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: D .I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF �j No. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG.'/6 9-0 '70V^ STORIES / S NATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING ' Lie.or Reg.No. Date leecde C.-P- - C-I,�sf } rte -ate- 1 HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS 30 ON LOT AND USE I hereby affirm that I am exempt from the Contractor's ACGT`T License Law for the following reason (Section 7031.5, Busi- + 3307 ness and Professions Code): NO.PARKING I ��1e�jj� "0 I, as owner of the property, will do the work and the SPACES PROVIDED LITEMS structure is not intended or offered for sale (Section TOTAL 80 m 5O 7044,Business and Professions Code). CHECK h c�} CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 9.0.50 I Hereby affirm that there is a construction lending agency CHANGE .00 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name 0000_0001 8/ 3/89 PROPOSED MAX. OCC. ' Lender's Address 4858 1 AM 9932 I certify that I have read this application and state that the ' PERMIT FEE 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 b ; upon the above-mentioned property for inspection purposes. :3_g 9 SEE REVERSE FOR EXPLANATORY LANGUAGE X Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76M444 ri CE 875(11-84) MISCELLANEOUS APPLICATION I hereboraPCert that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate o$Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN [.8ADDRJENS BU ❑ Certified copy is hereby furnished. BUILDING ADDRESS CALITY❑ Certified copy is filed with the county building inspection' LocALIrY p /�e n� �1 �� ARESTde artment. /Y'Y (� oss Sr. Date Applicant NEAREST DISTRICT No. G UP E ROC SSED BY CROSS ST. i+I �j T. /� I' CERTIFIOATE OF EXEMPTION FROM WORKERS' LEGAL ` v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MA jyr.HWAt NO. OF BLDGS. STATE MAJOR SECOND LOCAL NO CIRCLE (This section need not be completed if the work involved TRACT NOW ON LOT US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) /6�a EXISTING BLDG,USE o ff SIZE OF LOT n _ • I certify that in the performance of the work for which this o permit is issued,I shall not employ any person in any manner OWNER AP as to become subject to the Workers' Compensation Laws.ate Applicant MAIL (' / OCCUPANCY GROUP o /n-�Ly, ADDRESS gS6 OL• J/� Sr v �hdJr�A,'o p� w G �- TEL$ ,�—�6SD OCCUPANT LOAD °- NOTICE,TO APPLICANT: If,after mak' this Certificate of CITY No. res 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 oI this permit shall be TRAILER USE GEOLOGY INSPECTION 11 No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION p' 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. PARKING SPACES REWD PROVIDED License Number Lie. Class • LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No. of FROM: To. INSP CTO R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sI ATURE iness and Professions Code). � PRESENT USE OF BUILDING FINAL APPROVAL J Lie.or Reg.No. Date / HOME OWNER-BUILDER DECLARATION' NO. OF EXISTING BUILDINGS ON LOT AND USE /T(f -� G A00Tea I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usi �(✓ S 3307 80.50 ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED ITS 1 structure is not intended or offered for sale (Section , TOTAL � 7044,Business and Professions Code). �. CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 80:511 I hereby affirm that there is a construction lending agency CHANGE e00 for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name Lender's Address PROPOSED MAX. OCC. 0000-0001 7I 3/89 �-1 i • 1 certify that I have read this O application and state that the PERMIT FEE 4300 1 AM 9:57 above information is correct.I agree to comply with all County ISSUANCE FEE u• ordinances and State laws relating to.building construction, and hereby authorize representatives of this County to enter TOTAL FEE on the above-mentioned property for inspection purposes. ,,,r •„ � � �� `'a�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi tee f9 Date