HomeMy Public PortalAbout6326 SULTANA AVE_Miscellaneous__ „>I WOF KERS'COMPENSATION DECLARATION 76M444
.I CE 875 (2-80) MISCELLANEOUS APPLICATION {�
I sure, y affirm that i have a certificate of consent to self COUNTY OF LOS ANGELES 7” C, BUILDING AND SAFETY DIVISION U
insure,or a certificate of Workers'Compensation Insurance,or II� �
a certified copy thereof(Sec.3800,Lab.C.) 1
Policy No. Company- 9
ompany FOR APPLICANT•TO FILL IN 'ADDRESS
ADDRESS
❑ Certified copy is hereby furnished. BUILDING { /; yl n LOCALITY
ADDRESS W wi �W I
❑ Certified copy is filed with the county building inspection _ NEAREST'
department. LOCALITY 1�i CROSS ST.
Date Applicant NEAREST �` y7 e„ DISTRICT NO. GR UP TY PROC SEWBY
CROSS ST. n f/ CONST/.'
CERTIFICATE.OF EXEMPTION FROM WORKERS' LEGAL �Ov �~�
COMPENSATION INSURANCE (• DESCRIPTION I LOT NO. BLOCK MAP - .2,0,d.3 HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL �-
NOOF SLOGS. Q.
(This section need not be completed if the work involved TRACT NOW ON LOT USE 20NE SPECIAL CONDITIONS
. O
by the permit is for one hundred dollars ($100) or less.) SIZE OF LOT �&a // XIUSE oSTING B Gf Q. 1 / J U
EIe
r
I certify that in the performance of the,work for which this I ��,���rrr I f1C
permit is issued, I shall not employ any person in any manner OWNER n
so as to become subject to the Workers' Compensation Laws. MAIL ` 0 OCCUPANCY GROUP E(/t,��J� U
ADDRESS � a
Date Applicant y_
NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL $ —47
7d OCCUPANT LOAD 7
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. I ❑ ❑ ( No Spec. Knowl. '
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION® Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT V (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the Busi-
ness
effect and Professions Code, and my license is in full force and PARKING.
.II I G SPACES RED PROVIDED
License Number Lic.Class 1�
LIMITED TIME USE
Contractor Date I DATE DATE
❑ p FRO TO:
I am exempt from the licensing requirements as I am a.
licensed architect or a registered professional engineer SIZE OFNO. OF / INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG., STORIES SIGNATURE
iness and Professions Code). L FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION ON.OF AND UNG BUILDINGS
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING ;2 4,0 S 8A
SPACES PROVIDED 11
❑ I, as owner of the property, will do the work and the 0 0 0 0 2 2
structure is not intended or offered for sale (Section
7044,Business and Professions Code). . PROPOSED USE OF BUILDING L O - 61.00
CONSTRUCTION LENDING AGENCY o 0 0;6 1,0 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit isI 0 2, 1 71—8 1
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.I agree to comply with all County I�SUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize,representatives of this County to enter I
up t eabove-mentioned roperty for inspection purposes. SE REVERSE FOR EXPLANATORY LANGUAGE
,eczc��✓ z /eo 9/-
ignature of Permittee bate I
I