HomeMy Public PortalAbout5730 RIO HONDO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) N� I SC E L LA N EO U S APPLICATION
I hereby affirm that I have a certificate of consent to self ICOUNTY O(i/jLOiANGELES 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 IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS 57 :Zn aQ^ZL A LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY1 e C 1 NEAR EST
department. L / CROSS ST.
Date Applicant NEAREST O� DISTRICT NO. GROUP TYPE P O ESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O JJr
COMPENSATION INSURANCE DESCRIPTION I LOT NO. -LOCK MAP HIGHWAY
NO. F BLD GS. STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of
SIZE OF LOT EXISTING BLD,£+. a
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER D +-144A,14 s�
so as to b co a subject to the Wo ers' n Laws. MAIL' OCCUPANCY GROUP 2�il
o
Date D Applica , ADDRESS
NOTI T APPLICANT: I , ter mg this Certificate of CITY, No 8� I ' �^Q OCCUPANT LOAD �
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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
�/ -fPanic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION �tA✓/� 19bP�9
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 z
effect. eke PARKING REq'D D PROVIDED D
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a
PROMS 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 SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUI DING
Lic.or Reg.No. Date ,
r
HOME OWNER-BUILDER DECLARATION NO. OF EXISTI G BUILDINGS AL1
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 4 CC a ir
License Law for the following reason (Section 7031.5, Busi A
ness aV Professions Code): NO. PARKING S3li
f
, as owner of the property, will do the work and the
SPACES PROVIDED , , 427.711
structure is not intended or offered for sale (Section 1 {I EM
7044,Business and Professions Code).)
TOTAL
PROPOSED USE OF HUI DING TLl T SIL 22-722-7 o 70CONSTRUCTION LENDING AGENCY CHECK 227.717
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 _
Lender's Address y{
PROPOSED MAX. OCC. UUUIy�—IJll17I 61111/93
�. Alli
I certify that I have read this application and state that the PERMIT FEE 0226 f�. All L-1f,
above information is correct.I agree to comply with all County ISSUANCE FEE to
ordinances and State laws relating to building construction,
and hereby authorize representatives County to enter TOTAL FEEp� 7d
upon file ab mentio����bns on pu ose.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ure o er a at