HomeMy Public PortalAbout6008 ROWLAND AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(11-84) M ISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a cerfl
tificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
' ADDRESS 6
M Certified copy is hereby furnished.. BUILDING
/�
ADDRESS Cop, LA �YQW t__ LOCALITY Q
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. 1 \ �• C CROSS ST.
Date Applicant NEAREST //((�� (—tl^,.' DISTRICT NO. GROUP TYPE 4PR.04qqD BY
CROSS ST. 00 QA4 Fr � CONST.CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL•COMPENSATION INSURANCE DESCRIPTION LOTNO. .-LOCK MAP NIGNWA; LOCAL
NO. (CIRCLE)
NO. OF HLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE+ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this c
permit is issued,I shall not employ any person in any manner owNER
so as to become subject to the Workers' Compensation Laws. MAIL ST OCCUPANCY GROUP o
�� AA??
Date•.°,�� Applicant. — uI
NOTICE TO APPLICANT: If, after making this Certificate of CITY �� ITvo�'Zgj?(p0CJ 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 ❑ No Spec. Knowl. E
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- No. of EZIrs
ness and Professions Code,and my license is in full force and n
effect. FS (�� PARKING REq'D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer slzE of NO.OF FROM: To: INSPECTOR'S
acting ift my professional capacity (Section 7051, Bus EXISTING BLDG. jCIO STORIES SIGNATURE
iness and Professions Code). i FINAL APPROVAL _
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
V-13 I
HOME OWNER-BUILDER DECLARATION NO. OP 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 and Professions Code): NO. PARKING 311
EI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section i (-i°g
7044,Business and Professions Code). 3 507 229.70
CONSTRUCTION LENDING AGENCY PROPOSED USE OP BUILDING
ITEMS
I hereby affirm that there is a construction lending agency %—?b9AQ;_=7
for the performance of the work for which this permit is TOTAL AL 229m70
issued(Sec.3097,% .`t i CHECK 220°70
Lenders Name
PROPOSED MAX. OCC.
i 4{/14GE °Jdl
Lender's Address
I certify that I have read this application and state that the FERMIT FEE
above information is correct.I agree to comply with all County I ISSUANCE FEE 2
ordinances and State laws relating to building construction, 13000—LIGOI s
32I '193
and hereby authorize representatives of this County to enter TOTAL FEE !�
U
o above-mentioned property for inspection purposes. v v-533 Z AM ISI°5 7
3-9 , SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date