HomeMy Public PortalAbout5558-5560 1/2 SULTANA AVE_Miscellaneous__ WORKLRS'COMPLNSATIONDLCLARATION 764
CE 87
' 4 (11 841- MISCELLANEOUS APPLICATION {�
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i hereby a cert that I have a certificate of consent to ser COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, ot o certricate't7f Workers Compensation Insurance,or
a cert4ed copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILOINo ��
wooE¢as
❑ Certified copy is hereby furnishedeuILOING 'SrJ�Jp
A
DOREee LOCALITY
❑ Certified Copy is filed wtth the county builduig inspection LOCALITY NEAREST
department EIAA CROSS ST
Dale Applicant NEAREST DIS CT rv0 aIIOUP TYPH PROCESSED EY
Coos. ST L 9s T O �3 DDN.T
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALerle
COMPENSATION INSURANCE DESCRnrION Lor NO aL..N 'R NS'^ STATE MAJOR SECOND LOCAL
NO OP BLDG. rvoP
(Thu section need not be completed If the work Involved TRACT SomwvIft) NOW DN LOT UE6 20NQ BP¢CIAL CONDITIONS
by the permit is for one hundred dollars (SI00) or lest) _ US¢ GI
I certify that in the performance of the work for which this SIZE of Lor S �� HxiSTINa Sitio Rr.(Irals
permit is issued, 1 shall not employ any person in any manner OWNER
e
OCCUPANCY GROUP as to become subject to the orkere Com nat n ws IL
AD oRHSeI *-20-7DateApplicant �_ ¢o
W
NOTICE TO APPLICANT If, after making this Certificate of CITY T No �pp,— R5— OCCUPANT LOAD O-
Exemption, you� should become subject to the \Yorkers
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION No Spec Knowl ❑
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under proviSons of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Bust- NO OF Exlr¢
ness and Professrons Code,and my license is in full force and
effect IPX Pw R¢ING
SPw CES Rao D PROvIDED
License Number Lic Class LIMITED TIME USE
Contractor Date - RAT. RAT.
❑ 1 am exempt from the licensing requirements as I am a RRN
licensed architect or a registered professional engineer SIZEOF O oP ' IN SF¢ roR a
01 SIGNwruw¢c
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORINES
mess and Professions Code) FINAL APPROVAL
Lm or Reg No Dale PRESENT USE OF BUILDING
'R EaML HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINoe 1
ON LOT AN USH ACCT..
I hereby affirm that I am exempt from the Contractor s
License Law for the following reason (Section 7031 5, Busi- _ -177
ness and Professions Code) NO P"MIND - r
❑ 1, v owner of the property, will do the work and the SFACES
PRovIDED 2 r 1 ITEMS
structure is not intended or offered for sale (Section 2 ,
7044,Business and Professions Code) TOO AL 93 . 00
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK ?3.0,
'1
hereby affirm that there is a construction lending agency CHARGE ,1717
for the performance of the work for which this permit is
issued(Sec 3097,Civ C)
Lender s Name
PROPOSED MAX Dec {JOi,IiJ—�iLiDy y/jJ�ri•'�
Lender's Address
I certify that I have read this application and state that the PERMIT FEE Qty>7 502-7 1 Allll:IJi
above nrorntation is correct I agree to Comply with all County ISSUANCE FEB
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mep�T�oned property far inspection purposes
�V • //►I(`/ /( I�15 n' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date