HomeMy Public PortalAbout4848 RYLAND AVE_Miscellaneous__ WORD*RS'COM!'ENSAT[ON DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirmcrt)that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,or a ertiricate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING r/
❑ ADDRESS d' .
Certified copy is hereby furnished. BUILDING r ,qn LOCALITY
❑ ADDRESS I/`Ss
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date Applicant NEAREST p DISTRICT NO. ROU TYPE P SSED BY
CROSS T. '�r 1� �� I
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `y'
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 8 4 U MAP p� HIGHWAY }
No. a-(/f O (C IRGLE) STATE MAJOR SECOND LOCAL a
NO. OF BLDGS.
(This section need not be completed if the work involved TRACTq10 -7 NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars (5100) or less.) %�J 6
USE
of f
SIZE OF LOT .516 SC !f�, EXISTING BLDG. tr
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner OWNER r I U
so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP W
ADDRESS (Itte
y
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY NoEL.
C�JOCCUPANT 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. KnOWI. ❑
deemed revoked. Panic D@VIC@s ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING'-
effect. SPACES REQ'D PROVIDED
License Number Lic.Class 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 NO. OF PECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. � � STORIES r IGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING j4S
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
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ;1 2 3 5 9 A
7044, Business and,Professions Code). PROPOSED USE OF BUILDING # o o D D 30
CONSTRUCTION LENDING AGENCY I - 80,50
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). 0 0 0 8 Q 5 o 5
Lender's Name PROPOSED MAX. OCC. 0 2 8 8 5
Lender's Address PERMIT FEE
_ PJ.U�
I certify that 1 have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE57-b
ordinances and State laws relating to building construction, TOTAL FEE t
and hereby authorize representatives of this County to enter Z5-D
upon t ie above-mentione property for inspect'i n pur oseSEE REVERSE FOR EXPLANATORY LANGUAGE
.� e'• tlfllis.�-- G .�
Signature of Permittee Date
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