HomeMy Public PortalAbout5410 PERSIMMON AVE_Miscellaneous__ , S'COMPENSATION DECLARATION
104 . . t CE 875(2-801
MISCELLANEOUS APPLICATION
I hereby affirm
that I have certificate of consent to self( COUNTY OF LOS ANG LES B ILD SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,ori
a certified copy thereof(Sec.3800,Lab.C.)
I I
BUILDING
Policy No. Company ; FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is hereby furnished. BUILDING y/ LOCALI v
ADDRESS 5 �/ '� '
❑ Certified copy is filed with the county building inspectionQ NEAREST '
department. LOCALITY , CROSS ST.
Date Applicant NEAREST • DISTRICT NO. GROUP TYPE PR SED BY
CROSS ST. C i�0� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOAF HIGHWAY STATE MAJOR SECOND L L }
NO. OF BLOCS. Ov (CIRCLE) M1
(This section need not be completed if the work involved, TRACT NOW ON LOT USE ONE PECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.)' U
USE OF
�/
I certify that in the performance of the work for which this! SIZE OF LOT EXISTING BLDG. Er–
permit
'permit is issued, I shall not employ any person in any manner OrNE ,� 0
so as to become subject to the Workers' Compensation Laws. MAIL +f�4 OCCUPANCY GROUP �� U
I ADDRESS' Ir� s Q
Date Applicant
TEr..
NOTICE TO APPLICANT: if, after making this Certificate of L.Aldly OCCUPANT LOAD
CITY No.
Exemption, you should become subject to the Workers' APP CATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you most forth-,
with comply with such provisions or this permit Shall be' TRAILER USE[:] GEOLOGY INSPECTION C] No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTPanic Devices
ION ❑
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING•
effect. SPACES REG'D O PROVIDED D
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE OATH
FROM: TO:
F1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional Capacity (Section 7051, Bus- EXISTING BLD 6. STORIES SIGNATURE
iness and Professions Code). i PRESENT USE OF BUILDING FINAL APPROVAL `
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the I
Structure is not intended or offered for sale (Section
7044, Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY 2 7 2 O A
I hereby affirm that there is a construction lending agency 1
for the performance of the work for which this permit is a a o o 2 2
'
issued(Sec. 3097,Civ.C.). 2 0 0 (j Q(�`
Lender's Name PROPOSED MAX. OCC.
Lender's AddressPERMIT FEE o c o 6 1,(; r
.�
I certify that I have read this application and state that the ISSUANCE FEE 7 021 -8C
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County to enter eW ,
upon the above-mentioned property for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE
r� /D-.2146'
�Si ature .Permit Date
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