HomeMy Public PortalAbout5062 SULTANA AVE_Miscellaneous__ I 'RKERS COMPENSATION DECLARATION
CE 875 12 80) MISCELLANEOUS APPLICATION {�
CE 875 �J
I rebyJ4ffirm that 1 have certificateof consent to Self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers
rs CompCompensation Insurance or
a certified copy thereof(Sec 3800,Lab C) '
Policy No Company 'FOR APPLICANT TO FILL IN ADDRESS n
ElCertified copy Is hereby furnished BUILD B:
❑ wCORRo LOCALITY
Certified copy Is filed with the county budding inspection NEAREST
department LOCALITY CROSS ST _
Date Applicant NRNRW RT OISTRICTr1 011rUP TYPE PRO O RY
CROs! 6TAnfz U CONRI/
CERTIFICATE Or EXEMPTION FROM WORKERS' LEGAL ° r
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK . HIGHWAY STATE MAJOR •eco Lout d
no OF eLDea Nom IclRue) 0
(This section need not he completed if the work Involved TRACT XOW ON LOT ua :oNE RP ECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less) '
n USE
OF
SIZE OF LOT /f` G%19TIX6 BLO6
I certify that m the performance of the work for which [hes
permit Is Issued, I shall not employ any person ni any manner OWNER U
so as to become sublet[ to the Workers Compensation Laws MAIL ,� OCCUPANCY GROUP
, ADDRESS y
De[ e Applicant
NOTICE TO APPLICANT If after making this Certificate of CITY a noL 0 OCCUPANT LOAD ?
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth011—K
ICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be T..iLER 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) NO OF EXIT.
9 (commencing with Section 7000)of Division 3 of the Bus,
ness and Professions Code and my license Is In full force and vw RK we
PAR IN
effect REDO PROVIDED
99
License Number Lie Class
- LIMITED TIME USE
Contractor Date D.T. DAT.
❑ I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer size OF No OF INSPECTOR a
acting In my professional capacity (Section 7051 Bus- EXISTING BLDG Ero RIMS �nI Y nwTUR¢
mess and Professions Code) - PRESENT USE OF BUILDING FINAL APPROVAL / —U�
Lie 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 Contractors ^
License Law for the following reason (Section 7031 5 Bu i
ness and Professions Code) NO PARKING ' A O �1 5 C II
r1
5'ACUS PROVIDED 4 8 L
❑ I as owner of the property wdo the work,and the �l�) f K,� I # ��w is�� 30
structure Is not intended or offered
ered fur sale (Section
7044 Business and Professions Code) PROPOSED USE OF BUILDING OI(� �I * - 8Q50
CONSTRUCTION LENDING AGENCY a • • 8 0,5'05
1 hereby affirm that there Is a construction lending agency 1
for the performance of the work for which this permit Is �6�1 6T86
Issued (Sec 3097'Civ C)
Lender s Name
PROPOSED MAX Dec
Lender s Address PERMIT FEE
c
I certify that 1 have read this on and state that the
above information Is correct 1 agreeTee to to comply with all County ISSUANCE FEE
ordman�es end [ate laws relating to budding construction TOTAL Pee
end y out nze epr ntatives of this County to enter
up a abov me I ne roperty for Inspection /p rpos s(r SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of mittee Date