HomeMy Public PortalAbout6229 RENO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(1 1-84) MISCELLANEOUS APPLICATION
I 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. AF
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS 1
Certified copy is hereby furnished. BUILDING
ADDRESS J-U O Allt LOCALITY TL e
❑ Certified copy is filed with the county building inspection LOCALITY
NEAREST
department. 79a.%am CROSS ST.
Date Applicant NEAREST / AveDISTRICT NO. 6 U TYPE PRO SSED BY
CROSS ST. /r(i +N/ 4 /\ CONST.`'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1 6�
COMPENSATION INSURANCE DESCRIPTION LOT NO.Nn'/s-t 9 BLOCK _A. MAP HIGHWAY
NO. (CIROL6) STATE MAJORS OND LOCAL
r NO. OF BLOCS.
(This section need not be completed if the work involved TRACT S9a'f NOW ON LOT L USE QNE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. 1
X '� a
I certify that in the performance of the work for which this p
permit is issued,I shall not employ any person in any manner OWNER pl —$p� �c — y
so as to become subject to the Workers' Compensation Laws. Ocnn16 S
J P MAIL OCCUPANCY GROUP C
J'm ' U
Date ADDRESS Applicant u,
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of CITY No. $L$) —j 7gr I y
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 ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
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 f �/y�
effect. y 6W- `�C PARKING REq'D PROVIDED
SPACES
License Number Lic. Class - ¢ LIMITED TIME USE
Contractor Date 7D ATE DATE
❑ I am exempt from the licensing requirements as I am a kildwol.,
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 SIG ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTINGBUILDINGS
ON LOT AND USE 7 4 21 A
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- # o a O O 3 0
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED 1 - - 8(150
structure is not intended or offered for sale (Section
7044,Business and Professions Code). O 8Q5056
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING o7.07-87
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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
b
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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date