HomeMy Public PortalAbout4815 RYLAND AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 200063DPW12/90 MISCELLANEOUS ' APPLICATION
I hereby affirm Shat 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,oi'a dertificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800. Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING o �J
BUI AD ESS ADDRESS
F1 Certified copy is hereby furnished. f �, t V LOCALITY /
❑ Certified copy is filed with the county building inspectionJcmzIPNEAREST
department. ,Q Lv e j q/79O CROSS ST.
Date Applicant SIZE OF ICOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE .J ESSED BY
CERTIFICATE OF-EXEMPTION FROM WORKERS' —3 CONST. T/ O
COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP HIGHWAY V
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This seetion need not be completed if the work Involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
1 certify That in the performance of the work for which thisEADDUREtS
ER TEL NO. D
permit is issued, I shall not employ any person in any manner e.461 6 4v— R46 LU
so as to become subject to the Workers' Compensation Laws. ,3 OCCUPANCY GROUP — NDate Applicant / +ZIP
NOTICE TO APPLICANT: 'If, after making this Certificate 5 11,1lkJ OCCUPANT LOAD
of Exemption, you should become subject to the Workers' I APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forthwith
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
revoked.
No Spec.Knowl.' El E]L'T
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS
and Professions Code,and my license is in full force and effect. I
Q /��'V `�`•'�� -+ PARKING
License Number, LIc.Class' /� �( � SPACES REQ'D � PROVIDED
I � - �jjyLGCG /C�G�f''•�G�
Contractor Date x - V� y LIMITED TIME USE
❑ I am exempt from the licensing requirements as 1 am a G1�.vlca G� FROM: DATE TO: DATE
licensed architect or a registered professional engineer
acting in my professional capacity(Section 7051.,Business SIZE OF N .OF INSPECTOR'S
and Professions Code). EXISTING BLDG. STORIES SI ATUR
LIC. Or Reg.NO. Date PRESENT USE OF BUILDING FINAL APPROVAL f'�7•���
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS SO
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's License ACCTe$
Law for the following reason (Section 7031.5, Business and
r essions Code): NO.PARKING 37603 �(�• n��
I, as owner of the property will do the work and the SPACES PROVIDED VV
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING 1 ITEMS
Business and Professions Code).
• TOTAL 242.70
CONSTRUCTION LENDING AGENCY CHECK 242070
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE .00
(Sec. 3097,Civ.C.). PROPOSED MAX.OCG
Lender's Name APPLICANT(PRINT) TEL NO. �y
Lender's Address ADDRESS 0000-0001 11/ 6/95
1 certify that 1 have read this application and state that the 3167- 1 PM12-039
above information is correct. I agree to comply with all County PERMIT FEE
ordi antes and State laws relating to building construction,and
he y authorize representatives of this County to enter upon ,ISSUANCE FEE `(7 '
tit above-mentioned prope ty for inspection purposes. .
- / TOTAL FEE rJ i7
t1- 6—�J SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date