HomeMy Public PortalAbout5726 SULTANA AVE_Miscellaneous__ r''
��' ' 'OkKERS'COMPENSATION DECLARATION 76M444
I ICE 875(11-84) MISCELLANEOUS APPLICATION
I hereby a 11% that I have a certificate of consent tself I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insu9, or a ce ltificate of Workers'Compensation Insurance,e,or I
a certified copy thereof(Sec.3800,Lab.Q. '
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. ; UILDING
ADDRESS 2 SLl Avenue
LOCALITY
Certified copy is filed with the county building inspection OCALITY Temple Cit CA NEAREST
department. City, CRPSS ST.
Date Applicant I NEAREST T , DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. Las Tmu�as CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOW ON LONO. OF T S' USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($1.00) or less.) USE OF
M1}.
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
John M. Conover o
permit is issued,I shall not employ any person in any manner OWNER s�
so as to become subject to the Workers' Compensation Laws. �7� p OCCUPANCY GROUP r-
_AIL . P.O. BOX 1508 O
Date Applicant
NOTICE TO APPLICANT: If after makingthis Certificate of CITY TEL' (818)285-9951 OCCUPANT LOAD D-
Temple Cit NO.
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION EI No Spec. Knowl. El
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS.
ness and Professions Code,and my license is in full force and
effect. PARKING REq'D D PROVIDED O
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date OATS DATE
I am exempt from the licensing requirements as I am a PROMO TOI
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE
iness and Professions Code). Office FINAL APPROVAL
RESENT USE OR BUILDING
Lic.or Reg.No. Date
�L� /77
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT ANO USE ,
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi n
ness and Professions Code): NO. PARKING 2 9 8 5 9 A
❑ I,'as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section # o o•o o 8 8
7044 Business and Professions Code). . � y
' USE OR BUILDING Office q 0 0 0 0 0 0 0
PROPOSED
CONSTRUCTION LENDING AGENCY q,�
I hereby affirm that there is a construction lending agency v 0 610"88
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX.OCC. '
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
an4 hereby authorize representatives of this County to enter TOTAL FEE ID V
n the a ve-menti] p �perty for inspectio p rposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee ate