HomeMy Public PortalAbout5723 ROWLAND AVE_Miscellaneous__ "WORKERS'COMPENSATION DECLARATION 875 (2-80)
CE MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have certificate of consent self 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.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. Bu" NG 7�� ���1 A � / � LOCALITY
ADDRESS / `AI
❑ Certified copy is filed with the county building inspection t��/ NEAREST
department. LOCALITY �.e_W� CI 1 / CROSS ST.
Date Applicant NEAREST , DISTRICT�Q�O. GRO P TYPE 'ROC D BY
CROSS ST. L��le 00.K i�'U�/ � CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
rvo. (CIRCLE) STATE MAJOR SECON LOCAL >
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. ' tr
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 All r0
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W
ADDRESS gylq.(L N
Date Applicant TEL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY e v,�Q�CI kY No. 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 USEGEOLOGY INSPECTION
deemed revoked.
E] ❑ No Spec. Knowl. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION . Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) a
NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. Q w, PARKING.SPACES REq'D E== PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am y
licensed architect or a registered professional engineer SIZE OF NO. OF a INSPECTOR'S
acting In my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES 1 SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL C
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON L07 AND USE # O O O O
I hereby affirm that I am exempt from the Contractor's 1 0 0 8(1rJ 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING 8 Q 5 0
❑ I, as owner of the property, will do the work and the SPACES PROVIDED O O O
structure is not intended or offered for sale (Section 0 506-85
7044,Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
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.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE D,do
—
I certify that 1 have read this application and state that the ISSUANCE FEE -0
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction, TOTAL FEE JWP ^
and hereby authorize representatives of this County to enter IOU,J
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
=T_ 4- Sf,
S gnature of Permit ee_�- Date