HomeMy Public PortalAbout5120 PERSIMMON AVE_Miscellaneous__ i WORKERS'CObiPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby 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 LJ
a certified copy thereof(Sec.3800,Lab.Q.
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS �l f
❑ Certified copy is hereby furnished. BUILDING %MjMMM LOCALITY
ADDRESShiLo
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO GFPU& TYPE PR SEG BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLc) STATE MAJOR SECA. LOCAL
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT ' US ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) use of -e.? II� I
SIZE OF LOT EXISTING BLDG.
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 � 7 C'
so as to become subject to the Workers' Compensation Laws. MAIL ` OCCUPANCY GROUP �� a
ADDRESS VJX ; fie C~O
Date Applicant TEL
NOTICE TO APPLICANT: If, after making this Certificate of CITY T e C No.aJZ 44.i 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.
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 Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REq'D PROVIDED
SPACES
License Number Lic. Class 1
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF ah NO. OF I INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. OV STORIES 1 SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
51 Ie �wrn I I r ham e
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE # 0 0 0 0 3 0
I hereby affirm that I am exempt from the Contractor's SI n le ( o o $a 5 O
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): No. PARKING o 0.5 0 U=
I, as owner of the property, will do the work and the 8
SPACES PROVIDED O O O
structure is not intended or offered for sale (Section —7 -88Q Il, 4
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency B12
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
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.FEEW.
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ate
S' ature of Permittee