HomeMy Public PortalAbout6226 SULTANA AVE_Miscellaneous__ WUItKERS'COMPENSATION DECLARATION CE 875(17.84) M ISCELLANEOUS APPLICATION
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s, CE 875
I iliereby 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING .
wDORess
Certified copy is hereby furnished. BUILDING LOCALITY LOCALITY
ADDRESS
Certified copy is filed with the county building inspection LOCALITYNEAREST
department. CROs. ST.
Date Applicant NEARE. DISTRICT G OUP TYP PRO ESSED BY
CROSS SJJ
a CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor No. !�, BLOC �(1 MAP HIGHWAY
No. (CIRCLE) STATE MAJOR ND LOCAL
SE
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT UST SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
/l�eJ`(J'
SIZE OF LOT EXISTING BLDG. O}..
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER - S'
so as to become subject to the W rkers' Compen tion Laws. MAIL OCCUPANCY GROUP o
ADORES.
Date 1 Applicant ��1 /
NOTICE TO APP ICANT: If,after making this Certificate f CITY Sa TEL O_Q-44—13 '�D OCCUPANT LOAD z
Exemption, you should become subject to the Worke s' 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 ❑ No Spec. Knowl.
deemed revoked.
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 SPACES REQ'D PROVIDED
LL�� JJ
License Number Lic. Class / LIMITED TIME USE
Contractor Date Lti lrf A1 4 3 DATE DATE
�r
0 I am exempt from the licensing requirements as I am a p e PpOM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSGEATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING L
I MAI
A-27232A
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE # 0 0 0 0 0 0
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- lo e 8 G 5 0
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED DO ° 8 0.5 0=v
structure is not intended or offered for sale (Section
7044,Business and Professions Code). o6. 1 1 -87
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING l
I Hereby affirm that there is a construction lending agency ZA4 QLAJ0
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct.1 agree to comply with all County ISSUANCE FEE r S v
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE I
uq?!� above-m;ntio c( perty for inspection purposes.
�J SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Permittee Da e