HomeMy Public PortalAbout6278 PRIMROSE AVE_Miscellaneous__ AVORKERS'COMPENSATION DECLARATION 76M444 MISCE LLANEOUS APPLICATION
P CE 875(11-84)
hereby affirm that I have a Certificate of consent to self
nsure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
I certified copy thereof(Sec.3800,Lab.C.). �.
'ollcy No. Company FOR APPLICANT TO FILL IN BUILDING +7
Certified copy is hereby furnished. BUILDING ADDRESS /`.
❑ ADDRESS „? /
Certified CO LOCALITY
py is filed with the county building inspection LOCALITY.��l� i E j �i NEAREST
department. L r 1 CROSS ST.
Date AgpIicant NEAREST DISTR CT O. G O YPE PROCESSED BY
CROSSST. o Ch1 _r.e. L-v 6 �r--y CON
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ; / ��J//
COMPENSATION INSURANCE DESCRIPTION LOT NO. O ( BLOCK V MAP HIGHWAY
STATE MAJOR S
(This section need not be completed if the work involved TRACT3'Q`S NO. OF BLDG$. NO. (CtR GLH) EGO LOCAL
!
by the permit is for one hundred dollars ($I00) or less.) NOW ON LOT USOE SPECIAL CONDITIONSr+A USE OF
SIZE OF LOT (0 8 EXISTING BLDG. �""' �,,,,
[ certify that in the performance of the work for which this o_
permit is issued,I shall not employ any person in any manner A R(� o
OWNER t
50 as to became subject to the Workers' Compensation Laws. MAILApp OCCUPANCY GROUP
Date DDRESS Applicant 6 a 7 $ pr14 R 05TE
� A
NOTICE TO APPLICANT: If, after making this Certificate of CITYT�III t_ ('1 NOLAOV� '-61 0 ,, OCCUPANT LOAD N
Exemption, you should become subject to the Workers' �
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be USE TRAILER GEOLOGY INSPECTION
❑ ❑ No Spec. Knowl.
deemed revoked
Panic Devices
OCCUPANCY INSPECTION E]LICENSED CONTRACTORS DECLARATION ❑
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 �. !1} /
effect. P�� +J /�l1 f r PARKING REQ'D I PROVIDED
I I
SPACES
License Number Lic. Class of Jr `
Contractor Date
LIMITED TIME USE
DATE DATc
I am exempt from the licensing requirements as I am a FROM: TO;
licensed architect or a registered professional engineer 1ZE OFNO. OF INS CTOR•S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES i ATURE
mess and Professions Code). r
Lic.or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL171
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). `9 210 A
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING t O O a o 9 0
I hereby affirm that there is a construction lending agency
1 -8Q Q 0
for the performance of the work for which this permit is O O D S a 5
issued(Sec.3097,Civ.Q.
Lender's Name 0319—S8
Lender's Address PROPOSED MAX. OCC.
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 State laws relating to building construction,
and hereb thorize representatives this County t enter TOTAL FEE
upon the a men 'oned pmperI spection pur ses. `
3 t SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee D• e