HomeMy Public PortalAbout6032 RENO AVE_Miscellaneous__ 1M4a41VOIjKER9'•CONfPENSATION DECLARATION 76 - •�•. ;
CE 875..(11-84) M ISCELLANEGUS AP:P:LICATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILD'IN;G.AND.SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab..C.).
Policy No. CompanyBUILD.INGY' ' +'
FOR APPLICANT TO FILL IN ADDRESS >'7 : _Few U
Certified copy is hereby furnished. BUILDING _ ; 4�
ADDRESS U rj rL() LOCALITYCertif
department. CROSS is filed with the county building inspection LOCALITY / i� GI ( CNEAREST
ROSS 3T. I L Q 1
Date Applicant NEAREST I 111111 VVVV ��1 DISTRICT NO, GROUP TYPE PR CESSED BY
CROSS ST. RAM ° r�0 /j yn�� co NST. _
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d e h/
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP +HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLDGS. No. (CIRCLE)
(This section need not tie completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) SIZE OF LOT 50X 15; USE of
EXISTING BLDG: d
I certify that in the performance of the work for which this _
permit is issued,I shall not employ any person in arty manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL ADRESS l� OCCUPANCY GROUP 3
D (� V
Date Applicant I„
NOTICE TO APPLICANT: If, after making this Certificate of CITY L� t:f Tr TEL
7� Zb-T OCCUPANT LOAD y
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FO_i EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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 andp
effect. r` `' �—i� PARKING
SPACES REQ'D O PROVIDED
J D
License Number Lic. Class /V I �•I /� ` t t o
LIMITED TIME USE
LIPContractor Date LI l Z DATE DATE
ElI am exempt from the licensing requirements as I am a PROM. TO.
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
SIGNATU
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. J0 1', S STORIES
2 RE
iness and Professions Code).
PRESENT USE OF BUILDING DE, FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS �L
ON OT AN USE
L +'••.
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Bust- ,
ness and Professions Code): NO. PARKING i fl
0 I, 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). _,.
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ` 'i= -.•-
for the performance of the work for which this permit is i
issued(Sec.3097,Civ.C.). P191) Q �t
Lender's Name
7 PROPOSED MAX. OCC.
Lender's Address
PED.B'd "i.:.'!'.! .w :'��'? •''7'�':i.
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 to enter TOTAL FEE "— +
upon : ove-ment"onedigropertyfor inspection purpose
E REVERSE FOR EXPLANATORY LANGUAGE
VAU
•Signa ure f ye7 'tovvvvDa e