HomeMy Public PortalAbout4955 PERSIMMON AVE_Miscellaneous__ C' Kim'2S'COMPENSATION lll.C1.ARATION
'. CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
f hereby affirm that a 1 have a certificate of consent to self
nsure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
l certified copy thereof(Sec.3800,Lab.C.).
Poli No. Company FOR APPLICANT TO FILL IN FU5RZONffi_PF__CIAL
Cy yCertified copy is hereby furnished. BUILDING 955 Pei �mYh 1 "C .
ADDRESS ///►►► AF Certified copy is filed with the county building inspection LOCALITY 'P ' (_department. . {JDate Applicant NEAREST T.Np GF;�UP TYPE PROCESSED BCROSS ST. ',y �� CONT.CERTIFICATE OF EXEMPTION FROM\YORKERS' LEGAL � l0 COMPENSATION INSURANCE DESCRIPTION LOT NO� �, 9� BLOCK NIGNWAv STATE MAJOR SdOND LOCAL
(CIRCLE)
NO. OF BLDGS. /1(This section need not be completed if the work involved TRACT NOWON LOT rJ E SPECIAL CONDITIONS
by the permit is for one hundred dollars (S100) or less.) � USE OF Ife CSIZE OF LOT �VEXISTING BIG. O..
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 a N /H J
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP f11 3 C5
MAIL Q / \' p
ADDRESS &924 �^ G /v
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY No- 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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
OCCUPANCY INSPECTION ❑ Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
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-
ness and Professions Code,and my license is in full force and / SGT �� ��„ 21�
effect. T PARKING REQ D PROVIDED
SPACES
License Number Lic. Class CleG�'� 2I^. �DI^ d/ U ��hlalo
yW LIMITED TIME USE
Contractor Date �vlyl !h t-' �Q6' /V°' DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a 2!"'
licensed architect or a registered professional engineer SIZE OF y - OF INSPECTOR'S
g p gin �bx�Lf �!'/�`� 17O / SIGNATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES J
iness and Professions Code). �
PRESENT USE OF BUILDING Se FINAL APPROVAL
Lic.or Reg.No. Date Z_&K/
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS -3 d neigse
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's / /p ri r 8 7 9 2 A
License Law for the following reason (Section 7031.5, Busi- 4ar am
ness and Professions Code): O. ARKING
SPACES PROVIDED 0 0 0 0 3 0
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section I D o80,50
7044,Business and Professions Code).
PROPOSED USE OF BUILDING o 0 0 8 a 5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Q ], 15—P8
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
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, r
and hereby authorize representatives of this County to enter TOTAL FEE J
upon t e�a�''o�e-mention prope for i spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature yfFermittee Date