HomeMy Public PortalAbout9122 PRIMROSE AVE_Miscellaneous__ WORitt?RS'C'OaiPENSATION DECLARATION MISCELLANEOUS APPLICATION
1. CE
CE 875(17-84)875
J 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 ABUILDING G�LZ
DDRESS I
Certified co is hereby furnished. BUILDING t Z '
Py y / LOCALITY (/
ADDRESS
FICertified copy is filed with the county building inspection LOCALITY y/ 1 NEAREST n�
department. ! e `4/ 'e CRO ss ST. •',' 4'�-�
Date Applicant NEAREST l /��� DISTRICT NO. G U TYPE PROCESSED BY
CROSS ST. ��(J /; _ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �i V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECON LOCAL
NO. OF HLD GS.
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT //Z/00 NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) JJ syn USE OF
SIZE OF LOT ((J z 'L/YV EXISTING BLDG.
I certify that in the performance of the work for which this w /
permit is issued,I shall not employ any person in any manner OWNER L,v u!S ko t/�1�Z/L y
so as to become subject to the Workers' Compensation Laws. MAIL / OCCUPANCY GROUP o
Date Applicant
ADDRESS/W 6 S, ! fV L ,
TEL. OCCUPANT LOAD EEJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY UL2
C✓q No. zly7 7e � y
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked. � Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
E]
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 Exlrs
ness and Professions Code,and my license is in full force andR
effect. 1571 • 't PARKING
SPACES REq'D D PROVIDED
�
License Number Lic. Class 07 J
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 NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGIJ�TURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS '
ON LOT AND USE �C 1 2 Q A
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- o O D D 3 Q
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED I - - 80,50
structure is not intended or offered for sale (Sectionx
7044,Business and Professions Code). °'° ° ��C. = C'
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING` 07.08—FP
I hereby affirm that there is a construction lending agency A5 C >� 1s/T� 6�d
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). LOQ'
Lender's Name
PROPOSED MAX. OCC.
Lender's Address �
PERMIT FEE �
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances nd State laws r ]sting to b ilding construction,
and here authorize repr ntatives of h' ounty to enter TOTAL, FEE Sv
upon t aboveYilentione roperty fo ns ction purposes.
a.� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee
66 Date