HomeMy Public PortalAbout5729 ROWLAND AVE_Miscellaneous__ WORKERS'C0:IIPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N
CE 875(11-84)
Inher, or
cept that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
ir►sur4, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. _ --Company_ — FOR APPLICANT TO FILL IN BUILDING
ADDRESS t�
Certified copy is hereby furnished. BUILDING n / n I
ADDRESS /JVD LOCALITY k
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. `/�1 T / A � y�r ^ / CROSS ST. ,t(
Date Applicant NEARESTCROSS ST. F,A`L/VLL/"I ` �� �'F G/�J vl DISTRICT ryp. G Up TYPE / PR SED Y
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `
f/fl oy 3 CONST. 1Y/
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAr HIGHWAY STATE MAJOR SEC O LOCAL
NO. OF BLDGS.
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT S O NOW ON LOT �. US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) usE of �
�
SIZE OF LOT C �(1 Q EXISTING DLDG. �
I certify that in the performance of the work for which this a
permit is issued, I shall not employ any person in any manner OWNER o-icT(;-tC I/' � ,FLttVC tom-&-e' �
so as to become subject to the Workers' Compensation Laws. MAIL
Date Applicant 7 OCCUPANCY GROUP ,� o
ADDRESS PO. /_1-6-K t`fTE
U
uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITYTacJi-�L49 e try NOL6/$-2K- 9Y3 OCCUPANT LOAD
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E]
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 L9 q%rt C- V,�s12c.! �jvI,-X S?.2'voe-
effect. PARKING REp'D PROVIDED
SPACES
License Number Lic. Class t" ` � 1i-Lt '�• LIMITED TIME USE
Contractor Date D ATC DATE
❑ I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE of +` NO. OF INSPE TO R'S
acting in my professional capacity (Section 7051, Bus- 6XISTIN6 BLDG. ( O STORIES SIG ATURE
iness and Professions Code).
Lic.or Reg.No. Date PRESENT USE OF BUILDING aJid2,K FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS -�2I y/ r 6
ON LOT AND USE 4- �1{�`{�.(L`' 'E,Vo G /9.4 A
I hereby affirm that I am exempt from the Contractor's + 0 0 0 0 3 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING Q /�
El I, as owner of the property, will do the work and the
SPACES PROVIDED o 0 8 Q 5 0
structure is not intended or offered for sale (Section o 0 0 80505
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING U;"1-!.V— 0 1,06-87
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
PROPOSED MAX. OCG.
Lender's Address — 77
I certify that I have read this application and state that the PERMIT FEE V.
above information is correct.I agree to comply with all County ISSUANCE FEE O
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon above-m ed p operty for inspection purposes.
ove- o( � SEE Rl'VERSE FOR EXPLANATORY LANGUAGE
SignatureofPermittee Date
1 1 X