HomeMy Public PortalAbout6358 SULTANA AVE_Miscellaneous__ ;WC-'RKERS'COMPENs;XTION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
1 hereby affierti fic at 'ofnave a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
,lsure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDINGORELOCALITY
El Certified
SS'Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date Applicant NEAREST DISTRICT NO. G UP 7-PIE
PE PRO SED BY
CROSS ST. 5165r. � NST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a
AA
COMPENSATION INSURANCE DESCRIPTION LOT NO. s elocK MAP HIGH-AV
(CIRCLE) STATE MAJOR SEC O D LOCAL CL
dr NO. OF BLOGS. O
(This section need not be completed if the work involved TRACT �' NOW ON LOT r USE ZONE FIAL CONDITIONS V
by the permit is for one hundred dollars (5100) or less.) usE OF
SIZE OF LOT EXISTING BLDG. �I L
I certify that in the performance of the work for which this O
k- 0
OWNER
permit is issued, I shall not employ any person in any manner ® CL
U
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP LU
ADDRESS
Date Applicant fn
NOTICE TO APPLICANT: If, after making this Certificate of CITY rTEL.
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 USEGEOLOGY INSPECTION
ElC3No Spec. Knowl.
deemed revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic DBVIC2S
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 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. &QA4 &A PARKING
SPACES REQ'D E:= PROVIDED
License Number Lic.Class A
LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a; b ITS 7 cf.)14441 /.5 CQC /AI/Alb'
licensed architect or a registered professional engineer SIZE OF ro 8pyg iyt . NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL '
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
�484.0A
NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION ON LOT AND USE # a O O O 3 0
I hereby affirm that- I am exempt from the Contractor's I e.0 8 4 5 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKINGSPACES PROVIDED ,- 08(15050
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 0 6 1 1 t 8 6
7044, Business and Professions Code). —
PROPOSED USE OF BUILDING ,
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. 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 ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
and h reby authorize representatives of this County to enter v
upo the abqve-meiltionedq property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
(57
Ignrapermittee Date