HomeMy Public PortalAbout6007 PRIMROSE AVE_Miscellaneous__ �v` RKERS'COMPENSATION DECLARATION ( CE 875(1 1-84) MISCELLANEOUS XPPLICATION
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 BUILDING C /f G
ADDRESS v *( .�(fl.�[,
Certified copy is hereby furnished. weneessL'7 I /�'/I,'!��'& LOCALITY
0 Certified copy is filed with the county building inspection NEAREST
LOCALITY 16 CR O.SS ST.
department. et T (>Q G�
Date Applicant NEAREST DISTRIGGT O. G O TYPE CONST. PROM 5 D BY
CROSS ST. —j✓]�L
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAPI (CIRCLE)HIGHWAY STATE MAJOR SECON OcAL
NO.OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT U ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this CD
permit is issued,I shall not employ any person in any manner OWNER fL}G �� �� A-lE[/ ='
so as to become subject to the Workers' Compensation Laws. MAIL ;OCCUPANCY GROUP o
ADDRESS •pD
EHI
Date Applicant
/ � TEL ' OCCUPANT LOAD O_
NOTICE TO APPLICANT: If, after making this Certificate of CITY y GE /C No. '7 - QZ� z
Exemption, you should become subject to the Workers' VgppLl •ATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAILER USE I] GEOLOGY INSPECTION ❑ No Spec. Knowl.•
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0
I hereby affirm that I am licensed under.provisions of Chapter " SAFETY PERMIT E] (I.IST•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: cS�i41/ �{/ V/(�IJ PARKING
• SPACES REQ'D � PRO.V ID ED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE GATE
FROM:' TO:
❑ I am exempt from the licensing.requirements as I am a
licensed architect or a registered professional engineer SIZE of NO. OF INSPEC R'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
SIG URE
iness and Professions Code). FINAL APPROVAL —�
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATIONNO. OF EXISTING BUILDINGS
ON LOT AND USE o
I- hereby affirm that I am exempt from the Contractor's I #g
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING �. o;o'8.Q'5 0
SPACES PROVIDED
I, as owner of the property, will do the work and the o e o 115 .
structure is not intended or offered for sale (Section t5
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
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.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
ordinances and State laws relating to building construction, ,
and.hereby authorize representatives of this County W enter TOTAL FEE
upon the above-mentioned pro erty for inspectio purposes.
X2/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Permittee / 7Dat