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Home My Public Portal About5727 SULTANA AVE_Miscellaneous__ "�vORKERS'COMPENSATION DECLARATION ICE 875(2.80) MISCELLANEOUS APPLICATION I twreby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION in;'are,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANTTO FILL IN Bu{LDING ADDRESS ❑ Certified copy is hereby furnished. BUILDING S LOCALITY ❑ AODREss Certified copy is filed with the county building inspection NEAREST department. LOCALITY &AG_ CJ cRoss ST. ? Date Applicant NEAREST DISTRICT N G P PE PRO ESSED BY CROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL AA COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MP HIGHWY NO. (CIRCLE( STATE MAJOR SECOND LOCAL NO. OF BLOGS. d (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS p by the permit is for one hundred dollars ($100) or less.) V USE OF ;SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this 46 permit is issued, I shall not employ any person in any manner OWNER 0 so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP �J V ADDRESS �Q I i ��"•• W Date n Applicant T NOTICE TO APPLICANT: If, after making this Certificate of clrY NoEL.. OCCUPANT LOAD Exemption, you should become subject to the Workers' APPL ATION FOR ! EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be 'TRAILER usE GEOLOGY INSPECTION 1 ❑ i . . deemed revoked. ❑ No SpecKnowl ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) I 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 PARKING. effect. SPACES ' REQ'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ FRO /A: TO:. I am exempt from the licensing requirements as I am y ` licensed architect or a registered professional engineer !SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES I SIGNATURE iness and Professions Code). T USE OF BUILDING FINAL APPROVAL, f� i" .� RESEN Lic.or Reg.No. Date �P HOME OWNER-BUILDER DECLARATION NO.OF EX STING 7 nSTING BUILDINGS ON LOT AND USE 3 6 I"1 I hereby affirm that- I am exempt from the Contractor's i #1 0 0 0 0 8.8 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PA KING 0 0 0 0 0 0 0 - ❑ I, as owner of the property, will do the work and the SPACES PROVIDED I 07. 05-83 structure is not intended or offered for sale (Section 7044,Business and Professions Code). OPOSED USE OF BUILDING ,41 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issue (Sec.3097,Civ.C.). Lender's Name I PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that 1 have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE i ordinances and State laws relating to building construction, TOTAL FEE / and her by authorize representatives of this County to enter upon a above-men roperty for inspe tion purposes. $EE REVERSE FOR EXPLANATORY LANGUAGE S ^.;., _/ Signature of ermittee �6 Date I �: i WORKERS'COMPENSATION DECLARATION 76M444 ' MISCELLANEOUS APPLICATION AD I CE 875(2-80) 1 hereby 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,o r I a certified copy thereof(Sec.3800,Lab.C.) '. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. Iio AdADDREss T� 7 n �, LOCALITY i I ❑ Certified copy is filed with the county building inspection / Nin AREST department. I LOCALITY ',L GROSS ST. 10 Date Applicant EAREST �1_ T DISTRICT NO. GR UP TYPE PR SED BY 1 CROSS ST. y d_SI �- G CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL D r COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } NO. (CIRCLE) STATE MAJOR SECO D LOCAL !L NO. OF BLDGS. V (T111S section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I �� tY I certify that in the performance of the work for which thish VV O permit is issued, I shall not employ any person in any manner WNER �� VUR�' U so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP LU ADDRESS O t1 Date Applicant to NOTICE TO APPLICANT: If, after making this Certificate of CO CITY / C/,&*Nr �V OCCUPANT LOAD z 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 or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION❑ I deemed revoked. No Spec. Knowl. ❑ I Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) I ❑ NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full force and . effect. PARKING SPACES REq'D D PROVIDED O License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ F I am exempt from the licensing requirements as I am a ,ROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF IN PECTOR' acting In my professional capacity (Section 7051, EXISTING BLDG. STORIES ,n IGNA/TUR Bus- iness and Professions Code). / f A0.4:r) FINAL APPROVAL /y/ // ENT USE OF BUILDING (/K !v (/l•C� Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's 0 8 8 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and the # G G o O 8 8 structure is not intended or offered for sale (Section D O o o D o O 7044, Business and Professions Code). POSED USE OF BUILDING fq 71 I 0,09=84 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name PROPOSED MAX. OCG. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize represe atives of this County to enter guon ubcve-men o e p perty for I pectin purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 3--�� LT ignature f Permittee Date I I i WORKERS'CO-NIPENSATIOWI)ECLARATION 7S 44 (11-84) MISCELLANEOUS APPLICATION - I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING A- D- -sAF`E'I'YD�VISION •• insure, or a certificate of Workers'Compensation Insurance,or ; ___�— a certified copy thereof(Sec.3800,Lab.Q. i i Policy No. Company FOR APPLICANT TO FILL IN ADDR E55.NG /f�7 �` L_ DOR ❑ Certified copy is hereby furnished. -$ ADDRESS .S22- N 2 S�G'�j41/a ��• LOCALITY I I Certified copy is filed with the county building inspection X _LOCALITY NEAREST department. - 'rE3�+pE2 f/+ cstoss ST. Date Applicant NEAREST �a, D15TR ICT NO. GROUP CONS TYPE CESSED BY CROSS ST. . • 14 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL CO.NIPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP (CGRCLE}HW STATE MAJOR SECOND LOCAL NO. OF BLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF a SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which -itis 1 _ permit is issued, I shall not employ any person in any mannef-:g--owNER DQ,tAvii� so as to become subject to the Workers' Compensation Laws. g .MAIL OCCUPANCY GROUP 2�::] ' ADDRESS 33 S. Date applicant — TEL. -_ NOTICE TO APPLICANT: If,after making this Certificate of ciTY No. OCCUPANT LOAD 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 or this permit shall be TRAILER USE I] GEOLOGY INSPECTION 1 No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter ❑ n t �• 9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT (LIST ITEMS BELOWI NO. OF EXITS ness and Professions Code,and my license is in full force and J effect. �—�' P PARKING REO•D PROVIDED N SPACES License Number Lic. Class LIMITED TIME USE H Contractor Date DATE DATE Z FROM: r0: -AI am exempt from -he licensing requirements as I am :t INSPECTOR'S D. licensed architect oI a registered professional en;ineer SIZE OF NO. OF SIGNATURE ? acting in my professional canaClt}' 1$ection 7051. Bus- EXISTING BLDG. i STORIES iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL _ Lic.or Rea.No. Date S I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT.AND USE I hereby affirm that I am exempt from the Contractor's I License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property. will do tite work and the SPACES PROVIDED structure is not intended or offered for sale iSection 7044.Business and Professions Code). CONSTRUCTION' LENDING AGENCY �'. PRorosED USE of BUILDING I hereby affirm that there is a construction lending agency I I for tite performance of the work for which this permit is issued(Sec.3097,Civ.C.). I _'0 Q Lenders Name PROPOSED MAX. OCC. -,0 Lender's Address a25.00 1� I PERMIT FEE I: I certify that 1 have read this application and state that the I.a • above information is correct.I agree to comply with all County ISSUANCE FEE I--• ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE l _upon the-above-mentioned property.For inspection purposes. g SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ptnnittee Date ,-0 A ' I WORKERS'COMPENSATION DECLARATION CE 875 r11.84) MISCELLANEOU'S APPLICATION � CE 875 •i heaeby affirm that i have a certificate of consent to!self I insure. or a certificate of Workers'Compensation Insurance.IJI COUNTY OF LOS .-ANGELES-' I BUILDING AND SAFETY DIVISION � a certified copy thereof ISec.3800.Lab.C.). (1 Lj Policy No. Company i FOR APPLICANT TO FILL IN aDORESS 7 . CJ Certified copy is hereby furnished. ADDRESS .1 , LOCALITY ` I i Certified copy is filed with the count} building inspection LOCALITY Tem le Cit cRoss sT. department. J P Y Date applicant NEAREST 1DISTRICT NO. GRVP TYPE P ESSED BY CR055 ST. �� CON CERTIFICATE OF EXEMPTION FROM WORKERS*' i LEGAL % I COMPENSATION 1\SCR.\\C1: DESCRIPTION LOT NO. iBLOCKx 1 MAI+ HIGHWAY ND. (CIRCLE) STATE MAJOR SECOND LOCAL I NO. OF BLDGS. + (This section need not be completed if the work invdlved TRACT NOW ON LOT USE TONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S100) or less.) USE of I !SIZE OF LOT KEXISTING BLDG I I certify that in the performance of :he work for•Which,dlis permit is issued. I shall not employ any ae:son in 1n}'manner OWNER so as to become stibiect to the Workers' Corrivensation Laws. r � MAIL OCCUPANCY GROUP I — ADDRESS - i Date .applicant I _ NOTICETO APPLY ANT: if. after makinc :!lis Certificaie IiiT.TYRe&Ah (11_] NO. OCCUP.4N-LOAD Exemption. y1311Aimild become sullied ',o he \\'n*kers' _ Compensation provisions of the Labor Code. you must forth- 4P LICATICN ��F i =XIT 4.4RC':V�:nE with COnIDI\• 11'lill such DIOT15:onti Or :his ^ermil shall be _RAILER JSE ( GEOLOGY INSPECTION No SCeC. Kno�:vl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONg� O I hereby affirm :flit I am licensed under provisions of Chapter SAFETY PERMIT I"1 (LIST ITEMS BELOW) i 9 (commencing with Section 000) of Division 3 AI the BUSY NO.NO. OF EXITS ness and P:ot'essions Code.and my license is in full force and effect. i PARKING REO O PROVIDED w $PC CES Cl License Number Lic. ass o i LIMITED TIME USE Contractor Date DATE DATE W ❑ ( IrR7M: TO: Z I am exempt from the licensing requirements :is [ am 1 mI licensed architect or a registered professional engineer SIZE OF No. OF I INSPECTOR'S Z acting in :m• professional -avacit� tion oll '0 1..iBti S- EXISTING BLDG. STORIES SIG TURE a inesslnd Professions Code l. I FINAL APPROVAL. U PRESENT USE OF BUILDING Y Lie.or Reg.No. Date 7 x I I HOME O\1'N17l2-lil'iLUER DECLARATION NO. OF EXISTING BUILDINGS ' ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's ( License Lav for the following reason (Section 7031.3. Busi- ness and Professions Code): NO. PARKING ❑ I, as owner of the property. will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section ( 7044.Business and Professions Cade). CONSTRUCTION LE•NDiNG AGENCY I X PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction lending agCn y 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 25.00 1 certify that I have read this application and state that the above information is correct.I agree to comply with all Coknty ISSUANCE FEE ordinances and State lab's relating to building construction. and hereby authorize representatives of this County to $nter TOTAL FEE 25.00 i I upon the above-mentioned property for inspection purposes. 00 C, 9 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date I ,