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Home My Public Portal About5603 PERSIMMON AVE_Miscellaneous__ WURKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I tire, o affirm icaeI have a certificate o£ consent tc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING j ©3 v ' ADDRESS �O eLOCALITY Certified copy 15 filed with the county building inspection LOCALITY �� G r NEAREST department. . CROSS ST. Date Applicant NEAREST I DISTRICT NO. GFFFJJJQQQUP TYPE - PR SSED BY CROSS ST. y ` ® v e P �� /` 2 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP/r-0��3 (CIRCLE) STATE MAJOR SECON LOCAL NO. OF BLDGS. J 2 (This section need not be completed if the work involved TRACT NOW ON LOT ;2__ USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of P Gf 5 I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. o permit is issued, I shall not employ any person in any manner OWNER LoS r +. �0rd I y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o Date ADDRESS Applicant 11 8�y LU NOTICE TO APPLICANT: If, after making this Certificate of CITY G f TEL. s r'- ]l O OCCUPANT LOAD ,r IF z Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code,you must forth- APPLICA ION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El 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 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 ♦`O LIMITED TIME USE Contractor Date I e-:23 DATE DATE D I am exempt from the licensing requirements as I am a -31a a a1hR nn 00 FROM: To: licensed architect or a registered professional engineer sI E OF NO. OF INS EcTOR'3 acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 'f GNATURE iness and Professions Code). FINAL APPROVAL !/ v PRESENT USE OF BUILDING /i 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 ElI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section ;2 6 4 1. A 7044,Business and Professions Code). a 0 cJ CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 0 0 0 §R 10 I Hereby affirm that there is a construction lending agency x 1,28-87 for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). 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 j ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter LT71TAL FEE upon the bove-mentioned property for inspection purposes. Z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date