Loading...
HomeMy Public PortalAbout5761 PRIMROSE AVE_Miscellaneous__ :��,VS xS'COMPENSATION DECLARATION CE 8754(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. Company FOR APPLICANT TO FILL IN BUILDING (- ADDRESS 6 Certified copy is hereby furnished. BUILDING /�✓Z-��NL/ZE���p� ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY-� /e �� NEAREST department. / CROSS ST. Date Applicant NEAREST ��A� � DISTRICT�Ir GR = TYPE PROCESS B CROSS ST. Y G /� CONST,./ CERTIFICATE OF EXEMPTION FROM WORKERS' JV LEGAL �((` (, COMPENSATION INSURANCE DESCRIPTION LOT NO. pO�� BLOCK // MAP HIGHWAY STATE MAJOR SECOND L CAL NO. (CIRCI.a) NO. OF BLD GS. (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) ��x�3� uSE of SIZE OF LOT EXISTING BLDG. r a 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 Z7 DA;/`C /�/���f1E•9 .i v so as to become subject to the Workers' Compensation Laws. _ OCCUPANCY GROUP MAIL ADDRESS IP%ZI �C/• �� Date Applicant TELp L„ NOTICE TO APPLICANT: If,after making this Certificate of CIT� 'e— �jr NO Q� Y0�� OCCUPANT LOAD y Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- A PLICATION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USC ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El 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 andT _1 © ' >/r effect. Y T /T PSPACES ARKING Rrm Wo PROVIDED License Number Lie. Class LIMITED TIME USE Contractor Date D ATQ DATE ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF / FROM: io: IN IG TOR acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGf1ATURE iness and Professions Code). ,�.0 PRESENT USE OF BUILDING �Q�'-'d�Aeii/eG FINAL APPROVAL Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILI]ING�,-,be cL ON L07 AND USE // /� I hereby affirm that I am exempt from the Contractor's ;9 7 4 1.3 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING a I g I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section o c o 8 Q 5 0 55 7044,Business and Professions Code). PROPOSED USE OF BUILDING - 7.0 6 G 8 7 CONSTRUCTION LENDING AGENCY 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 PROPOSED MAX. OCC. Lender's Address U 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 d ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE .� upon the above-mentioned proper foT inspection urposes. n SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date