The URL can be used to link to this page

Home My Public Portal About5504 RYLAND AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certif�.ate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING a n A v 2 ADDRESS 7 ❑ Certified copy is hereby furnished. BUILDING ADDRESS O LOCALITY Certified copy is filed with the county building inspection LOCALr ITNEAR EST department. le ceoss sr. P-a f Date Applicant NEAREST DISTRICCC��T N TYPEP CESS�E BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR ECON LOCAL NO. (CIRCLE) NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. O}... I certify that in the performance of the work for which this o permit is issued,I shall not employ any person in any manner OWNER /Y( /— y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS a& � CF.7 Date Applicant' u.I OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL' y 1 TE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLIC TION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. El ❑ No Spec..Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby-affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT ❑ LIST ITEMS BELOW NO. OF EXITS ness and Professions Code,and my license is hi full force and �► C L/tG N C l .s —C On/ PARKING effect. SPACES RSQ'D D PROVIDED D License Number Lic. Class Q 2- C-- I S / r LIMITED TIME USE Contractor Date 1�//��/ C + DATE DATE 0 I am exempt from the licensing requirements as I am a OF FROM: TO: V licensed architect or a registered professional engineer E OF NO. OF IN SPE CTO s Z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATU E idProfessions Code). )e FINAL APPROVAL '' V PRESENT USE OF BUILDING Lic.orrReg.Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS .7 AT ' Uy j ON LOT AND USE L. J)OLP A I hereby affirm that I am exempt from the Contractor's A'•=R � License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING _ �lL,-S El I, as owner of the property, will do the work and the SPACES PROVIDED � I I E structure is not intended or offered for sale (Section --e 7044,Business and Professions Code). TOTAL:L 93 m 00 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING HECK 93.013 I hereby affirm that there is a construction lending agency CHANE .00 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name �+ �} 14 { PROPOSED MAX. OCC. 131310 -13130 , 3 14"90 Lender's Addresses ,{r, I certify that.I have read this application and state that the PERMIT FEE O .,09 1 AM 11ft,62 above information is correct.I agree to comply with all County ISSUANCE FEE 00 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FES- upon the above-mentioned property for inspection purposes. SEE Av�r� �/� J '�r l�J SEE REVERSE FORXPLANATORY LANGUAGE. E Signature of Permittee Date • WORKERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) M ISCELLANEOUS.APPLICATION I herby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure;aft a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FI LL IN BUILDING f� /� '(� I^.�� ADDRESS Q�f Certified copy is hereby furnished. ncnREss 5�O 1�.1\ 1 + �/�J LOCALITY r2-mA-- E Certified copy is,filed with the county building inspection LOCALITY % -�^ G GEAR sT. department. -(1f' p� At Qe2 Date Applicant NEARESTV� DISTRICT No. GROUP TYPE PROCESSED BY CROSS ST. W\ \�S , n ® CONS/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L O �/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP No. GIRe�E)RwnY STATE MAJOR SECOND LOCAL (eI NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. hO Z d I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER W, ,r =' so as to become subject to the Workers' Compensation Laws. MAIL 1 OCCUPANCY GROUP Z o ADDRESS 5 �l U Z] Date TEL'Applicant , Lu OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of c TYT No. — Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- wlth comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LAST 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. G exI CST i f1 Y7 1 PARKING SPACES REO'D D PROVIDED D License Number Lic. Class IS 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 OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES P '`` SIGNATURE iness and Professions Code). FINAL APPROVAL — / PRESENT USE OF BUILDING / Lic.or Reg.No. Date ZA!�i HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS -'!v ON LOT AND USE _ I hereby affirm that I am exempt from the Contractor's A U License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ?3.C-4 I 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). i W 93 . 00 PROPOSED USE OF BUILDINGF K •^+ CONSTRUCTION LENDING AGENCY (_ t• ,�°Iii( I hereby affirm that there is a construction lending agency CHANK .103 for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Ll�1Llll- l�l�l E ��' iIi�I(I Lender's Address _ I certify that I have read this application and state that the PERMIT FEE Cl— J. AN ii 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 — upon the above-mentioned property o ji0ection purposes. p a SEE REVERSE FOR EXPLANATORY LANGUAGE at of Permittee Date