HomeMy Public PortalAbout5451 SULTANA AVE_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875(2 MISCELLANEOUS APPLICATION
I &reb) 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 C )
Policy No Company FOR APPLICANT TO FILL IN_ woo ase .S (. .Q
Certified copy is hereby furnished BUILDING LOCALITY
❑
ADDS--- 5y SU 774-AJA 4V '7LCMA1-6 C1771
Certified copy B filed with the county budding mspectoon�
department LOCALITY �—�MPGE G CROSS ST ,Qpf}pW-q y
Date Applicant NEAREST DISTRICT NO I GROUP ITYPE rR0 SaHD-ey
CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP O ../ Ic Rw
N ew–V Iuwa°) arwre MwIoR D¢conD wcwL
(Thu section need not be completed If the work involved No of OLD" uaH zon¢ areclwL conolrlona a
TRACT NOW ON LOT 0
by the permit u for one hundred do0ars (5100) or less) U
use off
1 certifythat In the SIZE OF LOT ExuTING 191-00 1
performance of the work for which this `' p 0
permit Is Issued I shall not employ any person In any manner LONER EA,(j fes/ 0 >(PA44a-4 E
so as to become subject to the Workers Compensation Law MAIL f K OCCUPANCY GROUP U
A DDR
Date Applicant Q.
T¢L Q,�L "S(o�� to
NOTICE TO APPLICANT If after making this Certificate CITv7�IJ//�L� �'/ rvo 1 OCCUPANT LOAD Z
Exemption you should become subject to the Workers APPL CATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTIONEl
deemed revoked ❑ ❑ No Spec Knowl E]LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION 9i — Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bum
nese and Professions Code and my license is In full force and PARKING ('�
effect SPACES RED 0 1-.—J PR Ov mea O
License Number Loc Class
LIMITED TIME USE
Contractor Date OA.S OATS I
El I em exempt from the licensing requirements as I am a .I
z TO
I censed architect or a registered professional engineer o Srz¢OF NO oP INSPE row S
acting In my professional capacity (Section 7051 Bus- EXISTING BLDG aromE9 SIO ATURE
mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lm or Reg No Date—
HOMEOWNER
ateHOMEOWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE ;R7497A
1 hereby affirm that I am exempt from the Contractors # • • • * 30
License Law for the following reason (Section 7031 5 BIssI
ness and Professions Code) NO PARKING
SPACES PROVIDED
I as owner of the property will do the work and the 2'• • 8 0 5 0
structure is not intended or offered for sale (SLction • ° • 8 0 5 0
7044 Business and Professions Code) PROPOSED USE OF BUILDING
ux
CONSTRUCTION LENDING AGENCY 1209 -83
1 hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is
issued(See 3097 Civ C)
Lender's Name
PROPOSED MAX occ
Lender's Address PERMIT FEE O
I certify that I have read thison and state that the
above information 1-q correct 1 agreeTee to[o comply with all County IsauwPleE FEE d
ordinances and State laws relating to building construction, TOTAL FEE Q� v
and hereby 31.111110117e representatives of this County to enter
upon the above mentioned pro arty for ms ection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
I Sign re of Permittee Date