HomeMy Public PortalAbout5141 SULTANA AVE_Miscellaneous__ WORKLRS'COMPENSATION DFCLARATION 78M444 MISCELLANEOUS APPLICATION �T
11 CE 875 (1 801 q ,
II ureYy a crm that I have a certificateCpen of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION U
metre or a certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDINaC/
wooR¢ssS
❑ Certified copy Is hereby furnished Romana LOCALITY
❑ Certified copy is filed with the county budding Inspection /� NKA.E.T
department LOCALITYn/ ( 91790 corona ST
Date Applicant NEAREST Q— DISTRICT No aR P TYIE PRO nQD QY
CRO88 8T _SG S Q D/Q �` ) _� CONST ,
CERTIFICATE OF EXEMPTION FROM WORKERS' L¢awL �a f/
COMPENSATION INSURANCE Dnec RIPTION Lor No eLocK IGNwwY
N (c Iw CLR) STATE MAJOR SECOND LOCAL a
NO OF OLDIE Q
(?7115 Section Heed AOI 1K completed d the WOIIC involved TRACT NOW ON LOT USH SONE 9IHCIAL CONO rrIONn U
by the permit IS for one hundred dollars ($100) or less)
USEOF
SIZE of LOT ¢xmTInrvc eLoc 2
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 OwrvER a U
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUPEP] W
�j 0.
' wD DRcsn j .S4C-r.Q ir/4 /J t/E y
Dale Applicant �J /J -
NOTICL TO APPLICANT If after making this Certificate of CITY/FrrpLE�" T CY/ NoL 30 — oa OCCUPANT LOAD ?
Exemption you should become subject to the WorkersPLICAEXIT HARDWARE
Compensation provisions of the Labor Code you must forth - TION FOR� K-7.
with comply with Such provisions Or this permit shall be TRAILER USE E] GEOLOGY INSPECTION
deemed revoked 0 /IVoP Spec Knowl El.),
- LICENSED CONTRACTORS DECLARATION OCCUPANCY INSP¢rnz41
oN Panic Devices ❑
1 hereby affirm that I Am hLensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) No OF EXIT%
9 (commencing with Section 7000) of Division 3 of the Bust
ness and Professions Code and my license Is in full force and Bin�jOO I'7/L d0 PARKING
effect t1l RED o PRovIO ED
License Number Lie Class JCA/12 01SAI
LIMITED TIME USE -
Contractor Date DAr% DwrR
TO
licensed
I am exempt from the beans requirements as 1 em a
licensed 'architect or a registered professional engineer s¢¢ of No of In PEeroR s
acting in my professional capacity (Section 7051, Bus- EXISTING SLOG aTORIES I IGNATURE
mess and Professtons Code) PREVENT USE OF BUILDING FINAL APPROVAL
Lie or Reg No Date
HOME OWNER BUILDER DECLARATION No of Ex'STING BUILDINGS
ON LOT AND USE
1 hereby affrm that I am exempt from the Contractors
License Law for the following reason (Section.7031 5 Bust
ness and Professions Code) NO PARKING
SPACES PROVIDED❑ 1404,8A
1, as owner of the property will do the work and the
structure Is not intended or offered for sale (Section # • • 0 6 ,30
7044 Business and Professions Code) PROPOSED USE OF BUILDINQ -
CONSTRUCTION LENDING AGENCY I - 8050
I hereby affirm that there is a construction lending agency % % % 80500
for the performance of the work for which this permit Is
issued(See 3097 Civ C) U 21 4-86
Lenders Name
PROPOSED MAX OCC
Lender's Address -
PERMIT FEE r
I certify that I have read this application and state that the ISSUANCE FEE /
above Information Is correct I agree to comply with all County V•J
ordinances and State laws relating to buildingconstruction TOTAL REE '
and hereby authori presentatives of this County to enter
ozo
upon th ve 9crawfied operty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date '