HomeMy Public PortalAbout5830 SULTANA AVE_Miscellaneous__ VOR)KERS'COMPENSATION DECLARATION CE 875(11-84)
� MISCELLANEOUS APPLICATION
, �'� CE 875
I hereby firm that I have a certificate of consent to self
insure,:or? certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a cert ifibd copy thereof(Sec.3800,Lab.C.).
PQliCyNo. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS ✓✓ /-/'��
❑'Cerf'lf1`ed copy is hereby furnished. BUILDING UV LOCALITY
ADDRESS L/
❑ Cer&ied copy is filed with the county building inspection LOCALITY / NEAREST
department. Lm- CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY
CRO35 ST. TvAj � //�J� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ���
COMPENSATION INSURANCE DESCRIPTION LOT NO. 6(J BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OR BLO GS. NO. (CIRCLE)
(This section need not be completed if the work involved TRACT D NOW N OLOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) y� USE OF
SIZE OF LOTEXISTING BLDG.
I certify that in the performance of the work for which this �
permit is issued,I shall not employ any person in any manner 0wNER�f
so as.to become subject to the Workers' Compensation Laws. MA L /^/ OCCUPANCY GROUP
ADDRESS CSO 6
Date Applicant
TEL..Z
QW
NOTICE TO APPLICANT: If,after making this Certificate of CITY 5AN19166.0 No 6/% 6!J/ �71_15y 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 GEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS-DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 PROVIDED �- I
SPACES J
License Number Lic. Class &14 W_ t .� rbc Q>< �� LIMITED TIME USE
Er /'`8,7A . &-e_.44 u.L�f S6:
Contractor Date DATE DATE
•�-'/Gds t'j FROM: TO:
I am exempt from the licensing requirements as I am a � �/ � ; ��0. /uo {7: 6"1
licensed architect. or a registered professional engineer sar.OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING 5� Y�i��1 FINAL APPROVAL
Lic.or Reg.No. Date ppGG/
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE '
I hereby affirm that I am exempt from the Contractor's At-CT.a
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED
1 ITEMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL 93 . L30
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING :HECK 93.00
I hereby affirm that there is a construction lending agency CHANGE .00
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name I PROPOSED MAX. OCC. 13130113-101001 12/21/90
Lender's Address PERMIT FEE 4631
1 M10026
I certify that I.have read this application and state that the /2 r
above information is correct.I agree to comply with all•County ISSUANCE FEE ✓
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL.FEE
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
er�to Date