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Home My Public Portal About4824 RYLAND AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-841 MISCELLANEOUS APPLICATION CE 875 I hereby affirm 'that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or,a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN PCROSS NG SS �'�� a+•'L!� Certified copy is hereby furnished. BUILDING j Ab DR ESS 04 re. TY Certified copy is filed with the county building inspection LOCALITY , r ST department. �� C ST. Date Applicant NEAREST 11 rp /� P / DISTRICT NO. G UP TYPE PR CESSED BY CROSS ST. At I��Y` �(.�� W �LI�� CONST. 1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ///�� V COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK ra0 MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT !?!D '7 NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of I certify that in the performance of the work for which this SIZE OF Lor �Q Z© EXISTING BLDG. �` g -� A-1 7 ' o permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP MAIL. 41, ADDRESS Date Applicant a NOTICE TO APPLICANT: If, after making this Certificate of CITY`S 0/,0 `jj No. �� OCCUPANT LOAD Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. 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 EXITS ness and Professions Code,and my license is in full force and effect. PARKING REQ'D 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 FROM: TOI licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING � Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's MCCU. IF License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ;� 'I iTE1i� I, as owner of the property, will do the work and the SPACES PROVIDED � structure is not intended or offered for sale (Section X71 4L 9 . 013 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK I,:. I_i I Hereby affirm that there is a construction lending agency I i;ANGE for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name 0,0011-1000 : PROPOSED MAX. OCC. 0,001 _l001 .6I'i0"(!N` Lender's Address 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 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL. FEE ,OD upon the above-menti red property for i spection purposes. r SEE ;R�VERSE FOR EXPLANATORY LANGUAGE Signature o Permittee Date y /