HomeMy Public PortalAbout6290 PRIMROSE AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76CE 8754,,,_$4, M ISCELLANEOUS APPLICATION
I hereby affirm that I 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.Q. i
Policy No. Company FOR APPLICANT TO FILL IN BUILDING /
ADDRESS
Certified copy is hereby furnished. OU'LDENG p / LOCALITY
S qADDR
Certified copy is filed with the county building inspection LOCALITY NEAREST G—
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE P((ROCE SSED BY
O15`.l G J�
CRSS ST. V���
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSAT10N INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
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.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this _ r
permit is issued, I shall not employ any person in any manner OWNER JO oj— c/O L L 1 11 FS o
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP _ o
Date Applicant ADDRESS M�()Se A J
NOTICE TO APPLICANT: If, after making this Certificate of CITY e _ l= 1 NO.. M— EZ-511 S_ OCCUPANT LOAD
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth- APPLICA ION FOR EXIT HARDWARE:
with comply with Such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know].
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 0/
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 /. /-
effect. 4T! � LC _�!� PARKING
SPACES REQ'D PROVIDED
License Number Lic. Class.
s LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registeredengineero ro: INSPECTOR'S
g professional SIZE OF NO. OF
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG, STORIES SIGNATURE
iness and Professions Code). N C FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date -7•- ;
1
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ..
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 3303 Loci
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): NO. PARKING PROVIDED i 1] Imo'
I, as owner of the property, will do the work and the SPAEM'S ��
structure is not intended or offered for sale (Section TOTAL _
7044,Business and Professions Code).
CHECK
PROPOSED USE O BUILDING (�•.:ti J{'e�'�'•.I
CONSTRUCTION LENDING AGENCY t;}j ��� a si
I hereby affirm that there is a construction lending agency r, ��. c
for the performance of the work for which this permit is - � '• i1fiNU J11"
issued(Sec.3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCG.
Lender's Address 0 Qj 0 f-00 0 1 10.{225.I j
PERMIT FEE
I certify that 1 have read this application and state that the _ ? y ;,rt
above information is correct.I agree to comply with all County ISSUANCE FEE o j�.S/j
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE a3 Lf
upon the above-mentioned liroperty for inspection purposes.
n, SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe
ittee Da