HomeMy Public PortalAbout6361 SULTANA AVE_Miscellaneous__ WnP,KERS'C0M1IPENSATIONDFCLARAIION E 875 (2-80)
CWSCELLANEOUS APPLICATION
� CE 875
r 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,or i
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING :{b'
ADDRESS V ! I
❑ Certified copy is hereby furnished. BADUDRESILDINS O G /3L LOCALITY
1it
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY ?�LG C/ CROSS ST.
Date Applicant NEAREST / �a�r / DISTRICT U TYPE PR S D BY
CROSS ST. (.iM �^/� 'D CONST'/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v& ✓✓✓Z I
COMPENSATION INSURANCE DESCRIPTION LOT NO. ,6 BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR OND LOCAL IL
NO. OF SLOGS. O
(This section need not be completed If the work involved TRACT %� NOW ON LOT USE ZONE SPECIAL CONDITIONS (J
by the permit is for one hundred dollars ($100) or less.)
USE OF M
SIZE OF LOT 2 EXISTING BLDG.
I certify that in the performance of the work for which this f O
OWNER
permit is issued, I shall not employ any person in any manner lL��/
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPF f�3 W LL
ADDRESS CO)
Date Applicant = �
NOTICE TO APPLICANT: If, after making this Certificate of CITY NOI � � �� OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
with
provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION❑ Flo Spec. Knowl.
deemed revoked. 'Panic Devices ❑
LICENSED CONTRACTORS DECLARATION ff
OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT'Q (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 ,i�L4sb—a JV &Pus6-0 PARKING.
effect. SPACES • REQ'D PROVIDED
/�t�Jt-'V�m �� 2/ ����
�License Number Lic.Cl
) ass W-nL of��J. LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer 51 ZE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES )GNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BilILDER DECLARATION NO.OF EXISTING 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- # I �.
ness and Professions Code): NO.PARKING 1 - - 8(150
SPACES PROVIDED
❑ 1, as owner of the property, will do the work and the o o o $Q,5 0 5,
structure is not intended or offered for sale (Section 0403-87
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
t
I certify that I have read this application and state that the
bo00
ve information is correct.I agree to comply with all County ISSUANCE FEE
dinances and State laws relating to building construction, TOTAL FEE
3 hereby authorize representatives of this County to enter Q•
In above- entioned property for inspectVn purposes. SEF REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date