HomeMy Public PortalAbout5409 ROBINHOOD AVE_Miscellaneous__ WORICi;RS'COMPENSATIONDECLARATION CE 875(11-84) 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.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
AD DR ESS 11�
Certified copy is herebyfurnished. BUILDING r Q \ "
ADDRESS -eyo
i
Certified copy is filed with the county building inspection LOCALITY /y ceoss sT. ' �t�/
department. T/� �.� C. T
Date Applicant NEAREST DISTRICT NO. UPPP TYPE PRO SSED BY
CROSS ST. OL ✓E ����/� /Y✓ S;/%� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v� ( J V
COMPENSATION INSURANCE DESCRIPTION LOT NO. .7, BLOCK MAP r/�/ IC Nw AY STATE MAJOR SEC ND LOCAL
NO. K'1 CIRCLE)
n / -7 O NO. OF BLDGS. /
(This section need not be completed if the work involved TRACT A/ NOW ON LOT US Z NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of
vr0 x IN
I certify that in the performance of the work for which this SIZE OF LOT �Q� EXIST TG BLDG.
permit is issued,I shall not employ any person in any manner OWNER �/�g/�g�[� y
so as to become subject to the Workers' Compensation Laws. MAIL
Date Applicant /J 1 OCCUPANCY GROUP o
ADDRESS �/0 /�6,4/Aw CLZ U
rEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY �p� �,� �% No.
Exemption, you should become subject to the Workers' gppL CATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE ❑ GELOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 Bu 1- NO. OF EXITS
ness and Professions Code,and my license is in full force and �
effect. l�� /o+��ieaO/�7 9� �ATii� PARKING REq'D PROVIDED
_ SPACES
License Number r Lic. Class /o 91vtb o570—eC.
LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a Oa5 O D
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: TO: INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OR BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness
usiness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code). ;9.7 2 5.6 A"
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # o•D o'e 3 0
I hereby affirm that there is a construction lending agency -1 o - 80.50
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). o 0 - 8Q505
Lender's Name
Lender's Address
PROPOSED MAX. OCC. O 1 1 6-$7
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 �Q
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE d:J
n the abov Fment' ned property for inspection urpos S.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Permittee Da e