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HomeMy Public PortalAbout5440 PERSIMMON AVE_Miscellaneous__ ,r'�. WORKERS'COMPENSATION DECLARATION CE 875(1 1-84) M I SC E L LA N EO U S�`A PSP L I C AT I O N I hereby,affirm that I have a certificate of consent tsett COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or , a certified copy thereelf(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BU ILD,NG J{ ADDRESS �o(/ Ve Certified copy is hereby furnished. BUILDING T !rYl ADDRESS,� � v GL LOCALITY29vo 1 / v Certified copy is filed with the county building inspection LOCALITY department. /?9 �J r/ 04 �7• "cRoss sT. /UGC ©!P Ad- Lp/5/ 117 mew Date Applicant NEAREST DISTRICT NO. G UP TYPE PROCESSED BY CROSS ST. v r5/ by la w � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL OCI (� COMPENSATION INSURANCE DESCRIPTION LOT NO. elocK MAP HIGHWAY ! HO: — IRCLF_) STATE MAJOR SECOND LOCAL NO. OR BLD GS. (This section need not be completed if the work involved TRACT /� NOW ON LOT USE ZONE SPE AL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of �/1 I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. Iv O permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL L> OCCUPANCY GROUP 3 0 Date Applicant ADDRESS �t /M,rnn v e NOTICE TO APPLICANT: If,after making this Certificate of ..Tv NOL / 3Q.2 OCCUPANT LOAD Exemption, you should become subject to the Workers' OF APPI ir4dTinm ftR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$�' 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 D PROVIDED D License Number Lic. Class SPACES 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 professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES sI ATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS M- 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 usi ness and Professions Code): NO. PARKING I y•,-H;I;,:•. -. �I, as-owner of the property, will do the work and the SPACES PROVIDED I._!IJ ,:,-�_}i _� i;.:: _�T structure is not intended or offered for sale (Section , ,f - i _ .._, 7,044,Business and Professions Code). f PROPOSED USE OF BUILDING "I''•sI' •J_I. �y CONSTRUCTION LENDING AGENCY -I — I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name I i I"`~i•)vi'6 "''I'' PROPOSED MAX. OCC. - '•' ' Lender's Address PERMIT FEE ,&e,B•O •'" - - I ` °''•� 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 a ordinances and State laws relating to building construction, d here uthorize represent tives of this County to enter TOTAL. FEE pont a-m ntion ro rty for i ection purposes. / N� SEE REVERSE FOR EXPLANATORY LANGUAGE I Signature o Permittee Date