HomeMy Public PortalAbout5558 RYLAND AVE_Miscellaneous__ �. WORKERS'COMPENSATION DECLARATION �E 87541�t 841 MISCELLANEOUS A P P L I C A T I O N
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. CompanyFOR APPLICANT TO FILL IN BADDREUILDINSG 15-5,5 �
`[ 1'`�/ S .�JJ (J
Certified copy is hereby furnished' ADDRESS -5!599�$� LAND AVE- LOCALITY
Certified copy is filed with the county building inspection LOCALITY "('EEMPI„F_ C�'7,'rY NEAREST
department. CROSS ST.
Date Applicant NEAREST �dGLiE DISTWT NO. GROUP OPE NS ROC SSEO`BY
GROSS GA 4J L O�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J
COMPENSATION INSURANCE DESCRIPTION LOT NO. 115 BLOCK NOP IORCL61 STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT Ib9S� NO. OF SLOGS.NOW ON LOT I USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) �/ ) .
SIZE OF LOT �� /� I05 EXISTING BLDG. I��ME' v �
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 GPe6pRy L. SANDRA V. ASHASRA4 ;'
so as to become subject to the Workers'Compensation Laws. MAIL r �y A�(� AM�/ OCCUPANCY GROUP' , o
ADDRESS .5-g5g IPYi�.kMP AMr-
Date Applicant
NOTICE TO APPLICANT: If,after making this Certificate of CITY TEEPWLE Lay Ck. NO. %010 40144,Dq— 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 USE GEOLOGY 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 'ROOhh ADID I-n0ki MA-V& I N
effect. PARKING SPACES REq'D PROVIDED I I
11JJ
License Number Lic. Class tAi ITff ouT TQM(TS
LIMITED TIME USE
Contractor Date l DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code).
PRESENT USE OR BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS _I
• 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 __IJ e 6-0.50
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section • .
7044,Business and Professions Code). j I T ;i -O 50
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING -
I hereby affirm that there is a construction lending agency �N.GlaFE �
for the performance of the work for which this permit is r ° yH . o Li
issued(Sec.3097,Civ.Q. "
Lender's Name
PROPOSED MAX. OCC. , s
Lender's Address GUY 1{I'I*l0 01
PERMIT FEE - -I .1
I certify that I have read this'application and state that the c j M ;,to 46
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 klKE
u on the above-me one perty for inspection purp ses.
' SEE REVERSE FOR EXPLANATORY LANGUAGE
S )re of Permittee Date