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Home My Public Portal About5714 PRIMROSE AVE_Miscellaneous__ •'WO$fltS'.50MPENSATION DECLARATION 75M444 CE 875(11-84) MISCELLANEOUS APPLIC=ATION 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.C.). Policy No. Company FOR APPLICANT TO FILL IN AUILDIN BUILDING Certified copy is hereby furnished. BUILDING / r ADDRESS / LOCALITY Certified copy is filed with the county building inspection LOCALITYG^ NEAREST department. !CROS !T. Date Applicant NEAREST Q�IJ Q/ DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. _ _^j CONST, CERTIFICATE.OF EXEMPTION FROM WORKERS' LEGAL J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCKNOP MIG~WA; gTATE MAJOR SECOND LOCAL NO. OF BLDGS. (CIRCLE/ (This section need not be completed if the work involved TRACT NOW ON LOT US z0�E SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) / USE of SIZE OF LOT X(/�� EXISTING BLDG. I certify that in the performance of the work for which this permit is issued,.I shall not employ any person in any manner OWNER � G. � u � y so as to become subject to the Workers' Compensation Laws. MAIL is ��.00CUPAIVCY GROUP o ADDRESS ! i r'ti •':• ,. '1 .'•._: Date ApplicantLJ NOTICE TO APPLICANT: If, after making this Certificate of CITY NE �j OCCUPANT LOADCn D- Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLICATION.FO IT HARDWARE: _ with comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. 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 BusiNO. OF EXITS ehess ffectnd Professions Code,and my license is in full force and /✓�� .� - 02 ,p� �S e 6a ?SESe PARKING SPACES REQ'D PROVIDED License Number Lia Class 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 �1 ^ f NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. / QO D - STORIES SI NATURE iness and Professions Code). L �` G FINAL APPROVAL 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 usiness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED #;26351 A m o 0 0 structure is not intended or. offered for sale (Section 3 D ' 1 7044,Business and Professions Code). r` `x �*�, G o80,50 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING o o o $ 0.5 Qij— I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 1. 1 6'=8.7 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 ,,d above information is correct.I agree t co ply with all County ISSUANCE FEE112 1 M29 ordinances a tate laws rely ' o ilding construction, and here thorize represent s o this County to enter TOTAL FEE upon t bo -mentioned p inspectio purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P tee D to