HomeMy Public PortalAbout5014 PERSIMMON AVE_Miscellaneous__ WORKERS',COMPENSATION DECLARATION CE 875(11-841 MISCELLANEOUS APPLICATION
I liereby 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 Qiereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO qI LL IN BUILDING 0
/
ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS .�Z 44 f(� LOCALITY
Certified copy is filed with the county building inspection LOCALITYNEAR EST
department. z CIZ OSS ST.
Date Applicant NEAREST z DISTRICT NO. GROUPTYPE CESSED BY
CROSS ST. � may_ A CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �.�lV rJf
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLDGS. NO. (CIRCLE)
(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.) USE of
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. c
permit is issued,I shall not employ any person in any manner OWNER — =-�
so as to become subject to the Workers' Compensation Laws. MAIL
Cf<s Z-141-0/41P
OCCUPANCY GROUP o
Date Applicant ADOR ESS v/ hi M 11 A/42 `� Z3
TEL OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of clrY '_ 9 No. jam' ,
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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION �/
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
1 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
Inness and Professions Code,and my license is in full force and _
.effect, PARKING REq'D PROVIDED
SPACES
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
❑•I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered profbssional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lie.or Reg.No. Date PRESENT U E OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _
�I
I hereby affirm that I am exempt from the Contractor's ON LOT AND USE s�1.V:�_ �
License Law for the following reason (Section 7031.5, Busi- : s ,
ness and Professions Code): NO. PARKING t�,-, r
SPACES PROVIDED z,{;,:_3 r,;
El I, as owner of the property, will do the work and the a-='`4 T.s
structure is not intended or offered for sale (Section1 F1 iiJ i
7044,Business and Professions Code). •: -
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING .�4 = 4—
I hereby affirm that there is a construction lending agency t o s
for the performance of the work for which this permit is -r _
26
issued(Sec.3097,Civ.Q. n:� s
Lender's Name
PROPOSED MAX. OCG.
Lender's Address I _ ,; If; j j,f
I certify that I have read this application and state that the PERMIT FEE �f �; C_c
%tis'1.
above information is correct.I agree to comply with all County ISSUANCE FEE ��,� -' API 11:fEt
ordinances an ate laws relating to building construction, i
and hereby au representatives of this County to enter TOTAL FEE
upon the abZVeAnentioned property for inspection purposes. AA
f _ _ SEE REVERSE FOR EX LANATORY LANGUAGE
Cnaiu f r ittee Date