HomeMy Public PortalAbout5225 PAL MAL AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(17-84)
A MISCELLANEOUS APPLICATION
.- CE 875
lereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
ure, or a certificate of Workers'Compensation Insurance,
e,or
ertified copy thereof(Sec.3800,Lab.Q.
PolicyNo.-Company BUILDING Z Z �—
P FOR APPLICANT TO FILL IN ADDRESS C
Certified copy is hereby furnished. n10,
oneess J'22 LOCALITY ��
0 Certified copy is filed with the county building inspection LOCALITY / NEAREST ''/ /�•
department. -'�� CROSS ST.
Date Applicant NEAREST (/J �/ DISTRICT Ilp. G Up TYPE
CONS P O ESSED BY
CROSS ST. (�I`L e " 1-51
V[7-J 3
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCA
NO. (CIRCLE)
//'' NO. OF BLD GS.
(This section need not be completed if the work involved TRACT
12 (j
NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
Us
OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this v C)
permit is issued, I shall not employ any person in any manner OWNER S4Nt)2M h k_t�
so as to become subject to the Workers! C pensaton Laws. / y� �d OCCUPANCY GROUPMAIL EK�
Date�a2' +/ ADDRESS s'z 27 {-�L I�17 O
Applicant iU
NOTICE TO APPLICANT: If, after making this Certificate of CITY�kn PJ t G i rTio� 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 oI tE]is permit shall be TRAILER USE ❑ GEOLOGY INSPECTION No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 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
eness ffect. SPACES
Professions Code,and my license is in full force and j D G„AL I e- !}R PARKING
SPACES REQ'D D PROVIDED
License Number Lic. Class r� /� LIMITED TIME USE
Contractor Date 'I r► N A /L Pe}
/J /�,y / p %��/ DATE DATE
PlPdf� ,�(Zrll / �.S,p 2�'7� FROM. TO-
I am exempt from the licensing requirements as I am a -�
licensed architect or a registered professional engineer slzE OF No. of INSP CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). r '' y /
PRESENT USE OF BUILDING G� ES f-[bt-LS'G FINAL APPROVAL ✓ .7 `' /f/ ,
Lic.or Reg.No. Date �i l�
AVY
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT ANI
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
131 A
ness d Professions Code): NO. PARKING
SPACES PROVIDED ` O'
FI, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code). ;' o o D o 30
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I o D 8 Q 5 C
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is c o - 80,505
issued(Sec.3097,Civ.Q.
Lender's Name I i 2-88
PROPOSED MAX. OCC.
Lender's Address �}
I certify that I have read this application and state that the PERMIT FEE V/
above information is correct.I agree to comply with all County ISSUANCE FEE U. SO
ordinances and State laws relating to building construction,
and)heeby authorize representatives of this County to enter TOTAL. FEE Ira Supoe abov entioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si atu of Per ee Date