HomeMy Public PortalAbout4910 RIO HONDO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76CE sie4(11-84) MISCELLANEOUS 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.C.).
Policy No. Company FOR APPLICANT TO FILL INBUILDING
ADDRESS11'7 10 /�1
V'
Ali? A
FiCertified copy is hereby furnished. BUILDING
ADDRESS , Rio /l AIALOCALITY
V
Certified copy is filed with the county building inspection LOCALITY / NEAREST 7�
department. �+'� CROSS ST.
Date Applicant NEAREST / w /!�.�� S DISTRICT NO. GROUP CONST. P CESSED BY
CROSS ST. �+rD �J,-� p'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING
I certify that in the performance of the work for which this BLDG. C"
mo/�i� a
permit is issued,I shanot employ any person in any manner OWNER �! `�L l AE_TC�(e.V `''
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
ADDRESS �
Date Applicant MAIL ��L TEL. V uJ
n/ OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY �-t 19t e T No. Z 7— 72 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 ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. El
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 and AWr PARKING
//-� �I ,/
effect. ` 1.1 I L T /' �` SPACES REQ'O PROVIDED
LL��JJ
License Number Lic. Class �� LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
El 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 SIG URE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING A
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE t�_.:1 1•i'•1 0
a4
I hereby affirm that I am exempt from the Contractor's
±,ti •C
License Law for the following reason (Section 7031.5, Busi- �_`I`I303".
ness and Professions Code): NO. PARKING
D1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section TOTAL ¢3'"'s-_45
7044,Business and Professions Code). `. —
PROPOSED USE OF BUILDING C-ACK i�T a4_I
CONSTRUCTION LENDING AGENCY 0 P _
'Hil`vE
I hereby affirm that there is a construction lending agency ' 1
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. --
Lender's Name 1;IjI '3�-1 L1- '. s
PROPOSED MAX. OCC.
1030Lender's Address � O J` � j AM 7 '•k`•
°
I certify that I have read this application and state that the PERMIT FEE
C;Vabove information is correct.I.agree to comply with all County ISSUANCE FEE (�
ordinances and State laws relating to building construction,
and hereby auth Ize representatives of this County to enter TOTAL FEE
upon t1 above- led ro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
^.�.
Signature of Permittee Date