HomeMy Public PortalAbout5002 RIO HONDO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(11-84) M I SC E L LA N EO U S APPLICATION
CE 875
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or atertificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.C.). '
Policy No. Company FOR APPLICANT TO FILL IN BUILDING V
ADDRESS
Certified copy is hereby furnished. BiI ILDING /�/�q'2 Qq gontt_o LOCALITY
ADDRESS oo oC. 1 0
Certified copy is filed with the county building inspection LOCALITY rI NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRIC O. UP TYPE 7RO SED BY
CROSS ST. S (,�( I� •� CTyo.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. 6 BLOCK RIG AU&ICY
No. (CIRCLE) STATE Mr/XC LOCAL
NO. OF BLD GS.
(This SBCtIOn need not be completed if the work involved TRACT16 q S NOW ON LOT USE ZO E SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) J usE of
SIZE OF LOT 7 �rbl EXISTING BLDG. Q.Q, 'j, CM
I certify that in the performance of the work for which this
.permit is issued,I shall not employ any person in any manner OWNER3a M e T 13b'0 G `2.,r' 9 o
U
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
^,0. C) ' y
Date ADDRESSI/Applicant I„
NOTICE TO APPLICANT: If, after making this Certificate of clTv .e C�' NOL, I� J1TE OCCUPANT LOAD r
Exemption, you should become subject to the Workers' APPLICA ION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions oI 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- 0 NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. 1 PARKING REq D D PROVIDED
- 17
SPACES JJ
License Number Lic. Class
LIMITED TIME USE
Contractor Date I DATE DATE
T
El I am exempt from the licensing requirements as I am a FROM: O:
licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR•S
acting in my professional capacity (Section 7051, BBs- EXISTING BLDG. ' STORIES S ATURE
iness and Professions Code). �� Od m FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING ,
HOME OWNER-BUILDER DECLARATION NO. OF OW LOT AND EXIUSE STING BUILDINGS
I hereby affirm that I am exempt from the Contractor's I AWXT.g
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING .39-17 �1vii il.
I, as owner of the property, will do the work and the SPACES PROVIDED i ITEMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code). r TOTAL 83 a 00
CONSTRUCTION LENDING AGENCY PROPOSED USE OF 90fikDTN@ 010 G a -e ' CHECK 83.00
I hereby affirm that there is a construction lending agency a M CHANGE J30
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. (�[)�Ifl�fl—ff-i•113 i/ '7 99
Lender's Address � n 5.fJiJ4J LILIJI (/7
PERMIT FEE dD 882
I certify that I have read this application and state that the r v .�2 1 AM p.if}
above information is correct.I agree to comply with all County ISSUANCE FEE 0
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
up I the above- ntio ed property for inspection purposes.
0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signur.o P rmittee Date i