HomeMy Public PortalAbout5608 PERSIMMON AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I Have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or "
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. CompanyBUILDING
' a FOR APPLICANT TO FILL IN ADDRESS Vey
` vl�lti�
Certified copy is hereby furnished. LOCALITY
BUILDING D nn
ADDRESS ��/� ��� �V `
Certified copy is filed with the county building inspection LOCALITY 1 ��, cRoss RAREST.
department. T/77 �� C/u
Date Applicant NEAREST /J_e DISTRICT NO. G OUP TYPE ROC SEED 19
PP L/d� G�,K /nom
CROSS ST. �J�I` CONST. 'w,,,y�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - D� ff^— /`�I"
COMPENSATION INSURANCE DESCRIPTION LOT NO. S BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
s section neenot completed the work NO. OF
(Thitid t bltd ifhk involved P TRACT LOT USE ZONE SPECIAL CONDITIONS NOW ON LOT
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 L07 (d X ��� EXISTING BLDG. 6F-1
o
permit is issued,I shall not employ any person in any manner OWNER zr Dallld
y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
Date Applicant ADDRESS 5-606 Pers /� OI7 W
NOTICE TO APPLICANT: If, after making this Certificate of CITY e_ /e_ CI� N07 8/8-*¢¢3-4727 OCCUPANT LOAD ra„
,
Exem tion
p ' you should become subject the WorkersAPPLICATION 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. e
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. .L� O PARKING
SPACES REQ�D PROVIDED
License Number Lic. Class ��U T/ ;r1_1 iNiru✓• /O LIMITED TIME USE
LLL��
Contractor Date ___ 1N w/^/-/� •y J_/� W10�- DATE DATE
I am exempt from the licensing requirements as I am a rJ A FROM. TO. INSPECTOR'S
licensed architect or a registered professional engineer SIZE OF NO.OF / SI ATURE
acting in my professional capacity(Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code). FINAL APPROVAL �_QQ
PRESENT USE OF BUILDING
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
7044,Business and Professions Code). # 8 6 a
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency 1 - - 8(150 x
° C.
for the performance of the work for which this permit is I' cJ
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 I
above information is correct.I agree to comply with all County ISSUANCE
d heANCE FEE
ordinances and State laws relating to building construction,
any authorize representatives of this County to enter TOTAL FEE J
upo above ntioned proWM for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee1 Date