HomeMy Public PortalAbout5069 SULTANA AVE_Miscellaneous__ AMRS'COMPENSATIONDECLARATION 76sn444 MISCELLANEOUS APPLICATION
CE 875(11 841 n
1 hereby affirm that l have a Certificateen of mInsur to ser COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '�IUII
Ina,rc, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Pohcy No Company FOR APPLICANT
,TO FILL IN wnou.ae S7, SUL7-i441A 4KE
❑ Certified copy is hereby furnished BUILOIna o6 LTIWA ✓� LE rT
wo ow Ea• LOCALITY
Certified copy u filed with the county budding inspection Lo eALrrY NEAREST
department TEH/�E C(7 C.
er P�/V r
Date Applicant NEAR¢.r DISTRICT no a onP •[ 0ROCE.EED sY
c.oe$ sr _ toner
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 09
COMPENSATION INSURANCE DKe..IPT,ON I LOT NO BLOC[ AlMIowwAY
NOF ELDae NO (...CL.) STATE MAJOR SECOND LOCAL
(Thu rection need not be completed if the work involvedvotved rwwcr noO v on LOT u$K zovE era clwL CONDITIONS
by the permit io for one hundred dollar ($I00) or less.) e1zK or Lor O USEaxlennor
G BLDG
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person many manner o Kq UIff 0ALSO
w as to become subject to the Workers' Compensation Laws
OCCUPANCY GROUPMAIL S/O� LTf / IA / �L
Date Applicant K\�8U TSAzA... IL_JI
mo
aNOTICE TO APPLICANT If, after making this Certificate of CITY 15"1 LF_ rT.K. T12' --�8S331OCCUPANT LOAD _
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE25
Compensation provisions of the Labor Code,you must forth ❑
with comply with such provisions or this permit shall be TRAILER U5E ❑ GROLCGY INSPKCTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices ED
I hereby affam that I am licensed under provrvons of Chapter .wr[TY PERMIT ❑ (LIST ITEM[ BELOW) a
9 (commencing with Section 7000) of Drvison 3 of the Busr NO or EXIT.
mess and Professions Code,and my hcense Is in trill force and
effect SPACEPARKING wsoD PROVIDED
SPACES
License Number Lm Class
LIMITED TIME USE
Contractol Date DATE DAYS
❑ I am exempt from the licensing requirements as I am a PROM
TO
licensed architect or a registered professional engineer Sita or no or INSPECTOR e
acting m my professional capacity (Section 7051, Bus- EXISTING BLOC 3 TSO FF ...I.. no wruwK
men and Profentons Code) FINAL APPROVAL
Lic or Reg No V Date Pw E.K Sir u$K or BUILDING
HOME OWNER-BUILDER DECLARATION NO Or KX'STING BUILDING. 30
ON LOT AND USK A�T.j
I hereby attain that I am exempt from the Contractor's
License Law for the followmg reason (Section 7031 5, Bust, ��
ness and Professions Code) NO PARKING 3307
251, as owner of the property, will do the work and the $PACKS PROVIDED 1 ITEM
structure is not mtended or offered for sale (Section
7044,Business and Professions Code) TOTAL 80.50
CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING CKICK 80'550
1 hereby aff-im that there is a construction lending agency
for the performance of the work for which this permit is
Issued(Sec 3097,Civ C) s
Lender's Name , �rtr�(t_rtr��
PROPOSED MAX occ GOOD-0001 8/17/89
Lender s Address ro / AM p
PHRMIT FHH O SSL' _ 1 Ail Vi19
I certify that 1 have read this application and state that the
above Information is correct I agree to Comply with all County ISSUANCE FEE � Q
ordinances and State laws relatug to building construction,
and hereby authorize representatives of this County to enter TOTAL PEE
upon the above-mentioned property for inspection purposes
U �./I _ SEE REVERSE FOR EXPLANATORY LANGUAGE
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S`egnaatturret-of Permittee