The URL can be used to link to this page

Home My Public Portal About5637 SANTA ANITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION I hereby a cert that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or 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 Q pDDRES Certified copy is hereby furnished. BUILDING - LOCALITY .�- ADDRESS 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. ROUP TYPE CESSED BY CROSS ST. n p _ CONS A CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MPP HIGHWAY.0. (CIRCLE) STATE MAJOR SECOND LOCAL 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 R } SIZE OF LOT EXISTING BLDG. �/_ 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 V i 1y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �-a o ADDRESS C~.7 Date Applicant TEL•• / OCCUPANT LOAD O NOTICE TO APPLICANT: If, after making this Certificate of clrY NO. ' — Z 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. 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 IM�ri� �� e ^� I effect. „ev O �� PARKING REq'D PROVIDED �.J SPACES JJ JJ License Number Lic. Class ►� car LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO. OF SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES n iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING a Lic.of 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 �W ljt]I?t1 tjt IL rj% 9/,:&z License Law for the following reason (Section 7031.5, Busi- �!' C ness and Professions Code): NO. PARKING 1 o i P11 3:3 ❑ 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). CONSTRUCTION LENDING AGENCY 9 PROPOSED USE OF BUILDING 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.Q. Lender's Name PROPOSED MAX. OCC. 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 herebythorize representatives of this County to enter TOTAL FEE 0C upo5.tli ve-me ned pro y for inspect rposes. I r 1 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Permittee ate I WORKERS'COMPENSATION DECLARATION 2000 SDP, 90 MISCELLANEOUS APPLICATION • - I hereby'affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING:AND SAFETY DIVISION - j �msure,or a certificate of:Wdrkers'Compensation Insurance,or ; .a certified copy thereof(Sed.3800,Lab.C.) i Policy No COmpatiy FOR APPLICANT TO FILL IN BUILDING HBUILDING ADDRESS ADDRESS Certified copy.is.hereby:furnished. , S L6CAuTM Certified copy is filed with the county building inspection cl ZIP �p Q I department. Q M U� L 0� NEAREST OSS ST. Date •' ' Applicant SIZE OF LbT NO. BLOGS.NOW ON LOT DISUP_DISTRICT NO GROTYPE PROCESSED BY I CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. coNsr. O COMPENSATION INSURANCE MAP HIGHWAY V • No. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL by the permit is for one hundred dollars ($100) or less.) usE zoNE SPECIAL CONDITIONS 4— I.certify that in the performance.of the work for which this 3K�lj3� y eI TEL so as to become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP L{lba W tlsht+:, Date Applicant . CITYzIP NOTICE TO APPLICANT: If, after making this Certificate 6bL O OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the4gibor Code,you must forthwith EXIT HARDWARE: comply with such provisions Or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. revoked. ❑ ' ❑ ' LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) 1 9(commencing with Section 7000)of Division 3 of the Business game 6t ffu—siuess NO.OF EXITS and Professions Code,and my license is in full force and effect. . License Number LIC Class PARKING• REQ'D PROVIDED I ^ SPACES ' I Contractor Date ''t LIMITED TIME USE I ❑ I am exempt from the licensing requirements as I am a •• DATE DATE � P 4 FROM: TO: licensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES SIGNATURE. Lia or Reg Na - Date PRESENT USE OF BUIL NG FINAL APPROVAL >r m 6s f n ' HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS j ON LOT AND USE I hereby affirm that I antexempt from the Contractor's License Law for the following reason (Section 7031.5. Business and ' I Professions Code): NO.PARKING 1111 PROVIDED i ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING Business and Professions Code). i CONSTRUCTION LENDING AGENCY S •_•_ ' i' I hereby affirm that there is a construction lending agency for I the performance of the work for which this permit is issued (Sea 3097,Civ.Q. PROPOSED MAX.OGC. Lender's Name As6b NT fpRM)rJ C TEL NO C; Lender's Address ADDRESS I certify that I have read this application and state that the W t^' `�� (�S w citzi 0 above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives.of this County to enter upon ISSUANCE FEE , the above-mentioned p rty for inspection purposes _ .. � ` '. t .. !�•— TOTAL FEE . .. SEE REVERSE FOR EXPLANATORY LANG.UAGE Signatu a of Permittee Date 1 WORKERS'COMYhIVSAttUtV UCt LAKAttV1V 20-0063DPW12/90 WIN --c-l—L I hereby affirm that I have a certificate bf consent toiself COUNTY OF LOS 7AANGELES BUILDING AND SAFETY DIVISION { Tiasuret or a certificate of;V4'ijrkers'Compensation Insurance or a oerttfted copy thereof(Set?.3800,Lab.Q. - POlicy'No. Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS ADDRESS { Certified copy.is hereby;furnished I • -0 S"1gP,¢ A lk . uicALrrY 1 Certified copy is filed with the county building inspection CITY ZIP 1 department. . ! NEAREST . ! Date %' "• Applicant SIZE OF LOT NO,OF B GS.NOW ON LOT DRiS RIOSS OT No. GROUP TYPE PROCESSED BY CONST. �L CERTIFICATIr OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT No• O r COMPENSATION INSURANCE �„p N�wAr V (This section need not be completed if the work invojYed ASSESSOR MAP BOOK PAGE PARCEL NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. USE ZONE SPECIAL CONDITIONS � { by the permit is for one hundred dollars ($100) or less.) Q L certify that in the performance.of the work for which this �r { permit is issued:I shall not employ any person in any mapner 'Ac• I so as to become subject to the Workers' Compensation maws. ADDRE3� sromp, mt-C/30- LS. OCCUPANCY GROUP s/3 Date Applicant . �� ZIP �!_QD NOTICE TO APPLICANT: If. after making this Certificate =}'� OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-l*bor Code.you must forthwith EXIT HARDWARE: comply with such provisions or'thls permit shall be deemed [TRAILER USE GEOLOGY INSPECTION` revoked. No Spec.KnoWl. ❑ LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT O tusT rriems BELOW r - o 1 9(commencing with Section 7000)of Division 3 of the Busihess �� d •1181aeS8 NO.OF EXITS : and Professions Code•and my license is in full force and effect. PARKING { License Number Lie Class I ca � `„CA- Com` v1 a SPACES ' REO'D E= PROVIDED C� 1 Contractor Date LIMITED TIME USE El I am exempt from the Iicensing requirements as I On a DATE FROM: TO: DATE licensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business slzE OF NO.OF INSPECTOR'S and Professions Code). + EXISTING BLDG. STORIES SIGNATURE. Lic. or Reg.Na - Date PRESENT USE OF BUILDING FINAL APPROVAL 1 I HOME OWNER-BUILDER DECLARATION I NO.OF EXISTING BUILDINGS I ON LOT AND USE l I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5• Business,and I Professions Cade): 1 . NO.PARKING ' SPACES PROVIDED s ❑ L as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044,1 PROPOSED USE OF BUILDING i Business and Professions Cade). ? CONSTRUCTION LENDING AGENCY j' I'hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ` 1 (Sec. 3097,Civ.Q. I PROPOSED MAX.OCC. { Leuder's Name APPLICANT r 1 i y PL TEL ` +_ .. Lender's Address ADDRESS 'IVIf I certify that I have read this application and state that'the A• 6CLTA - <p { above information is correct. I agree to comply with all County PERMIT FEE { ordinances and State laws relating to building construction„and - ••• i •.,., { hereby authorize representatives.of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. .'h, ( � :•I;' ... I TOTAL FEE .. .. SEE REVERSE FOR EXPLANATORY LANGUAGE- S” igna a of Permittee Date