HomeMy Public PortalAbout6126 ROWLAND AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7E 76M444(11-84) M ISCELLANEOUS 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 /
ADDRESS
Certified copy is hereby furnished. BUILDING �/n�
ADDRESS / V LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY NEAREST V
department. V �f l ( CROSS ST. G
Date Applicant NEAREST CROSS ST. ��� DISTRICT No. JF� TYPE CESSED BY
�r� y CONSTCERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL GJ' Q e_l
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLD) STATE MAJOR SECOND LOCAL
NO. OF BLOCS.
(This section need not be completed if the work involved TRACT _?2_&yV NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) uSE of ` r
I certify that in the performance of the work for which this SIZE of LOT .01 EXISTING BLDG. L��
p //�� a
permit is issued I shall not employ an /i, tJ o
p p y y person in any manner OWNER o y
so as to become subject to the Workers' Compensation Laws. MAIL / OCCUPANCY GROUP
ADDRESS
(��L. 8
Date Applicant TEL. �y 1''
NOTICE TO APPLICANT: If,after making this Certificate of CITY 7 ���C%4`� No. I �� /���y 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.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION P11 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 EXITS
ness and Professions Code,and my license is in full force and
effect. t�� �/' /Z -dl-�_� PARKING RSQ'D PROVIDED
SPACES
License Number Lic. Class e—J LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a
FROM: To:
licensed architect or a registered professional engineer SIZE OF /,A� NO.OF INSPECTOR'S
acting in, my professional capacity (Section 7051, Bus- EXISTING BLDG. ���S r� STORIES SI A7URE
iness and Professions Code). c �A
Lic.or Reg.No. Date PRESENT USE OF BUILDING V��6 //+/r• FINAL APPROVAL. r' _
_ .•ice _ _• i
—J.
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE 0I AI 234 - 45
I hereby affirm that I am exempt from the Contractor's - r
License aw for the following reason (Section 7031.5, Busi- =°�_'.,'• �-- *-
nese Professions Code): NO. PARKING ;. .¢ �,� (-•
I, 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).
_Il{_�_—t_�:l
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 6� i
I hereby affirm that there is a construction lending agency i Qom./ � �*-'1== _ �`, •:•s_
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address a
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 7v
ordinances and State laws relating to building construction,
and hereby uthorize repress atives of this County to enter TOTAL FEE
p ove-mentioped perty for inspw4on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa a of ermittee Date