HomeMy Public PortalAbout6402 SULTANA AVE_Miscellaneous__ WOCJ1I`OMPENSATIONDECLARATION 76M444 M �SC ELANEOUS APPLICATION
CE 875(11-84)
I ]refeby arlt' fiat I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a c amp
of Workers'Compensation Insurance,or
fl
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING //�f ,{/7 LOCALITY
ADDRESS '� LIG t' f i \.7 G� / -'�� [�
ElCertified copy is filed with the county building inspection LOCALITY i GROSS sT.
department. ��17L e 1/
Date Applicant NEAREST DISTRICT'TNO G U TYPE PRO ESSED BY
cRoss sT.3C7wEEI�' t'�dt7`� rJ(f��/?r"�1 / 'r CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL //1 /_ U
COMPENSATION INSURANCE DESCRIPTION LOT NO&% LJ S BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR S OND LOCAL
(This section need not be completed if the work involved TRACT NO. OF BLDGS.NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 9 OF
US
SIZE OF LOT EXISTING 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 OWNER
P I P ,�•%A-{��/?• C.t G/tri �
so as to become subject to the Workers' Compensation Laws. MAIL jj ///`•• / r OCCUPANCY GROUP f� o
ADDRESS&ry//��>G /� • t-f I1/�i� r3
Date Applicant u"1
NOTICE TO APPLICANT: If, after making this Certificate of CIT . �,J ( Jf; L No� .`" ` .�S- 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 ❑
❑ ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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 O v L^ �/
effect. PARKING RVQ' D PROVIDED D
SPACES
License Number Lic. Class p/`�T. O '� � Jv°
,L. ' LIMITED TIME USE
Contractor Date r`i�=� OATS DATE
❑ I am exempt from the licensing requirements as I am a
FROM:
licensed architect oI a registered professional engineer SIZE OF • NO. OF INSPECTOR'S
EXISTIN BLDG. STORIES SIG TURE
acting in my professional capacity (Section 7051, Bus- O(2_..
iness and Professions Code). I`y USFINAL APPROVAL
Lic.or Reg.No. Date PRE EN E O HU LDIN
C
HOME OWNER-BUILDER DECLARATION NO. OF, EXISTING BUILDING• / „$61.8 A
ON LOT AND USE & G
I hereby affirm that I am exempt from the Contractor's O o 0 0 3 0
License Law for the following reason (Section 7031.5, Busi- -4---
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED - 80,50
_
structure is not intended or offered for sale (Section o o o $(j 5 0 u
7044,Business and Professions Code).
PROPOSED USE OF BUILDING L. l 1. 1 217 -87
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.Q.
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 Q
ordinances and State laws relating to building construction, S
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above�ment' ed propeFty for inspection urpcps.
?y� �r �, 7/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date