HomeMy Public PortalAbout5710 PRIMROSE AVE_Miscellaneous__ WORKERS' COMPENSATION DECLARATION 76M444DPw12/90 MISCELLANEOUS APPLICATION
I hereby affirmthat1 have a certificate of consent to 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 BUILDING ADD FOR APPLICANT TO FILL IN BUILDING •57/0 ��
SS ADDRESS O7 !V
❑ Certified copy is hereby furnished. _-j LOCALITY C
❑ -Certifiedcopy is filed with the county building inspection cI ZIP
department. (541 ?/ NEAREST
CROSS ST.
Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRIIyC NO. GROUP TYPE PROC
dlb / r I V I CONST. _.
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO: MAP , HIGHWAY
COMPENSATION INSURANCE
NO. (CIRCLE) STATE MAJOR SECON LOCAL, O
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS ''
by the permit is for one hundred dollars ($100) or less.)
I certify thai in the performance of the work for which this OVW TEL NO. OC
permit is issued, I shall not employ any person'in any manner L '� L° . 4 ���N � Tat_41g24 0
so as to become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP
Date Applicant I Y ZIPa
NOTICE TO APPLICANT: If, after making this Certificate _ OCCUPANT LOAD • Z
of Exemption, 'you should become subject to the-Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the tabor Code,you must forthwith
comply.v<ith such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ NO Spec.Knowl. ❑
revoked. ❑
❑ Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
E]
hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS IBELOW)
9(commencing with Section 7000)of Division 3 of the Business � NO.OF EXITS
and Professions Code,and-my license is in full force and effect. H/l+lif , �p ���
PARKING•
SPACES REQ'D O PROVIDED D
License Number Lic.Class. � � eli
Contractor Date LIMITED TIME -USE
❑
• DATE I am exempt from the licensing requirements as 1 am a FROM: TO: DATE
licensed architect or a registered professional engineer
IZE OF NO.
acting in my professional capacity(Section 7051;Business SXISTING BLDG. STORIES
oR's
IN r
and PTOfeSSIODS Code).
ENS' {� ES � S TORE
Lic; or Reg.No. Date ' PRESENT USE of BUILDING FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO.OF EXISTINGBUILINGS ACCT.
ON LOT AND USE 3303 �]��°7Q
I hereby affirm that I am exempt from the Contractor's License .G r
Law for the following reason (Section 7031.5, Business and //& ~ 1 ITEMS
PrQfessions Code): . • NO.PARKING
1, as owner of the property, will do the work and 'the SPACES PROVIDED : : - TOTAL 24.2.®70
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING CHECK Business and Professions Code). . .
CONSTRUCTION LENDING AGENCY a CHANGE °00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (7 (y(�(ry 8L
(Sec. 3097,CIV.C.). PROPOSED MAX.OCC 0000-000 4,
1 / 3/96
Lender's Name APPJ_ICANT(PRINT) TEL NO. 577 1 PM 6:06•�a�c.�� �6-
Lender's Address AD ESs A
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County pERMIT FEE _ /��
ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter upon ISSUANCE FEE a
the above-mentioned property for 'inspection purposes.
J/' TOTAL FEE f 91
" � T,3—g�, SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date -