HomeMy Public PortalAbout5423 PAL MAL AVE_Miscellaneous__ Wi RKE$S'COMPENSATION DECLARATION
CE 875(t 7 841 MISCELLANEOUS APPLICATION
CE 876 fI
1 heeetim that I have a certificate of consent to ser COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION nIL�II
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 wnnw¢sc 3
Certified copy i hereby furnished euILDINa Ne LOCALITY — e
ElCertified Copy is filed with the county budding inspection LOCALITYNEAREST
department C.o.E ST
Date Applicant NEAREST Olwrq lcT No OgouP Trr[ PRIMED BY
<RoeE Er Jr• mid y� con r
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/ I+
COMPENSATION INSURANCE DCaCR IPTI on LOT No .LOCK MA ID Nw wr
NOP (CIw CLw) STATE MAJOR [QC D LOCAL
N
(This Sectionon need not be completed if the WOrk involved TgACT NO OF YLOOO OIY ON LOT U! ON[ OPe C1AL CONDITION!
by the permit is for one hundred dollars ($100) or less) u•e or p
•'ze or Lor
I certify that in the performance of the work for which this QxIeTIN a
permit is issued, I shall not employ any person many mannOWNQP
er _
CD
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP,
Date Applicant wD.eaea � 'b.
U
W
NOTICE TO APPLICANT If, after making this Certificate of CITY C rTEL4446 07 ?/ OCCUPANT LOAD o-
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 D[e ❑ 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 Busr NO or EXITS
ness and Professions Code, and my license is in full force and n
EPACES F..,.KD
effect k PA RK IN O weO D D D
K
License Number Lic Class
LIMITED TIME USE
Contractor Date DATE DAT[
I am exempt from the licensing requirements as I am a ,D
licensed architect or a registered professional engineer size or No or INSPECTOR e
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES IGNATURs
mess and Professions Code) - PRESENT USE OF BUILDING FINAL APPROVAL 5
Lic or Reg No Date
HOME OWNER-BUILDER DECLARATION �� NO OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affum that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Bust
ness and Professions Code) NO PARKING
,
I, as owner of the property, will do the work and the SPACES PROVIDED ':1 5 0 Q 5-A
structure N not intended or offered for sale (Section !.�- �• .�, �' ' •� ,
7044,Business and Professions Code) • • • 030
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING ,•' �. ` �•� ,
� � � � ( • • 8(Iv5 Q
1 .
I hereby affum that there is a construction lending agency ` \; } \`� + �l +'�r\ �!
for the performance of the work for which this permit is • •�• 8 Q 5 D
issued(Sec 3097,Civ C)
.. - `
Lender s Name �' 'i� _� d `�( 07, 1�1 "8'61
PROPOSED MAX OCC
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the `
ti
above information is corect 1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL PEE
upon the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
EO :O.LI 14
Signature of rermittee Date /