HomeMy Public PortalAbout5548 SULTANA AVE_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875
' CE 876 (Z 80) MISCELLANEOUS APPLICATION {�
I L J
.I h6reby 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 CompanyFOR APPLICANT TO I LIN ADDRESS
BUILDING
❑ Certified copy Is hereby furnished ¢uILDINe iL
❑ ADORES• i%WLOCALITYB b
Certified copy led with the county building inspection i
department i Loux.. HaT
ury ewonRa ST
Date Applicant • NH0R¢ar oinTwlcr�/o olllpppuP TYPE PRo SCO Br
ewoLa Sr .,["'Qy y •y con
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL IP V O ^'J
COMPENSATION INSURANCE D¢ee Rienon LOT NO BLOCK NAP ICNWAv }
xo or ei.Daa
No (c lwc..cl nrwrH MAJOR sE D Lout 11
(This section perm need not be hndredcompleted ll the work involved rewcr NOW ON LOT Us on¢ SP eoxolTioxS O
by the permit u for one hundred dollars (5100) or less) �E//�z U
StzC OP Lor 3 HrrinriNo BLDG /\�
I certify that in the performance of the work for which this
O
permit E issued, 1 shall not employ any person in any manner OWNER LU
so as to become subject to the Workers' Compensation Laws NAIL OCCUPANCY GROUP W
ADDRESS a
Date Applicant - N
NOTICE TO APPLICANT If, after making this Certificate of ctry r eioL OCCUPANT LOAD Z
Exemption you should become subject to the Workers
Compensation pro%isions of the Labor Code, you must forth APP ATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER US¢
deemed revoked ❑ GEOLOGY INSPECTION❑ No Spec Knowl rn ❑❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPEON Panic Devices
I hereby affirm that 1 am hLensed under provisions of ChaptLr SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bust
ness and Professions Code and my license is in full force and r
effect e P RKlna
� i s ePwc¢S R¢O D E= PRoviDCD
License Number Lm Class
L LIMITED TIME USE
Contractor Dale ✓L
GwrR DwTR
r
1 am exempt from the hLensmg requirements as 1 em a
licensed architect or a registered professional engineer Size OF No OF INSPECTOR S
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG eTOR1¢S I NATURE
mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date �/
OF
HOMEOWNER BUILDER DECLARATION No ON LoOrT EXISTING AND D use BUILDINGS
I hereby affirm that I am exempt from the Contractors
License Law for the following rLason (Section 7031 5 Bust
ness and Professions Code) NO PARKING Ii
SPACES PROVIDED
ID1 as owner of the property will do the work and the • I '
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
PROPOSED USE OF BUILDING �{ ` ,.• y { C t A `
CONSTRUCTION LI NDING AGI NCY
I 8as,0�,
1 hereby affirm that
ce there is a k for chic lending agency �, _ 8 a5�a
for the performance ce of the work for which this permit is •s Lender
en de(sec 3097 Cir C> — 0 213-!-87
Lenders Name I
PwoPoe¢o MAX Oce
Lender a Address PERMIT FQe
I certify that 1 have read this application and state that the
above information is correct 1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding constructionTOTAL FEE
and hereby authorize representatives or this County to enter
opo Ie Dbose mentio it e y for inspection purposes SEF REVERSE I O XPLANATORY LANGUAGE
signa�of Perini t� Date