HomeMy Public PortalAbout6058 ROWLAND AVE_Miscellaneous__ _1,-WOR`CMS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATIONf�
hereby affirm that I have a certificate of consent tself CE 875(11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Inure, or a certificate of Workers'Compensation Insurance,e,ar
certified copy thereof(Sec.3800,Lab.C.).
olicy No. Company FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING
AD.R ESS 1: LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department.
F CROSS ST.
)ate Applicant NEARESTDISTRICT NO. GROUP TYPE ROC SSEDIBY
CROSS ST. I J ,ry Q �/�,ryr CON T.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL -57
69 v (I\ ^3
COMPENSATION INSURANCE DESCRIPTION LOT N tZ BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO.OF SLOGS. NO. (CIRCLII)
This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
Iy the permit is for one hundred dollars ($100) or less.)
USE of
SIZE OF LOT EXISTING BLDG, }.
certify that in the performance of the work for which this a
Iermit is issued,I shall not employ any person in any manner OWNER A ek
o as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP CC
Q
)ate Applicant ADDRESS
VOTICE TO APPLICANT: If,after making this Certificate of CITY_ifh
TEL OCCUPANT LOAD a
Exemption, you should become subject to the Workers' APPLICATION FOR
4ompensation provisions of the Labor Code,you must forth-
EXIT HARDWARE:
with comply with such provisions or this permit shall be I
TRALER USE GEOLOGY INSPECTION
❑ ❑ Ria Spec. Knawl.
Seemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION bo Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) o
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
effect. SPACESG REO'D PROVIDED
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE GATE
I am exempt from the licensing requirements as 1 am a FROM: 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 SIG ATURE
iness and Professions Code). }..
Lic.or Reg.No. Date PRESENT USE OF BUILDING 7+'i�w FINAL APPROVAL
ZJ
1
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 and Professions Code): NO. PARKING
DI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING ;25 31.7 A
I Itereby affirm that there is a construction Iending agency # 0 0 0 088
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. 1 0 0 8 Q 5 Q
Lender's Name
PROPOSED MAX. OCC. ,'ly O O O 8 Q 5 d C=.'.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE , [�(j �� ti� 0 a26-86
above information is correct.1 agree to comply with all County ISSUANCE FEE --7)
ordinances and State laws relating to building construction,
rtheeby authorize rep ntatives of this County to enter TOTAL FEE
bove-mention pro rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date