HomeMy Public PortalAbout6024 RENO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 44 (2-801 MISCELLANEOUS APPLICATION
I hereby affirm that I have 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.C.)
Policy No. Company ButLDING �J
FOR APPLICANT TO FILL IN pDL�RE55
ElCertified copy is hereby furnished. BUILDING �/�1 ��� LOCALITY
❑ ADDRESS .G T
Certified copy is filed with the county building inspection NEAREST /
department. LOCALITY / CROSS ST.
Date Applicant NEAREST i DISTRICT NO GROUP TYPEROCESSED BY
CROSS ST. _A/a G CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L ®
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. OF SLOGS. }
NO. fj (CIRCLE) STATE MAJOR SECOND LOCAL ti
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE ECTAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) USE OF /J
SIZE OF LOT EXISTING BLDG. ix
I certify that in the performance of the work for which this « 0
permit is issued, I shall not employ any person in any manner OWNER (� U
so as to become subject to the Workers' Compensation Laws. MAIL r OCCUPANCY GROUP SII III W
ADDRESS �S 0 0.Date Applicant to
NOTICE TO APPLICANT: If, after making this Certificate of circ No� Gi r ,� OCCUPANT LOAD Z
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE[JGEOLOGY INSPECTION NOSpec. Knowl. Eldeemed revoked. ❑ Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. REO'D I PROVIDED
SPACES
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity(Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
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 - -
G e u
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 T
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the _
structure is not intended or offered for sale (Section
7044, Business and Professions Code). FROPOSED USE OF BUILDING v v
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.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE �� r `� C �, • i
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE
—i� • t
ordinances and State laws relating to building construction, TOTAL FEE
3j�6&epresentatives of this County to enter . � � �ned pro rt y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�- L
ignature of Permittee Dat �r� 1 grA 01-e �