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Home My Public Portal About6411 SULTANA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 M I SC E L LA N EO U S APPLICATION fl CE 675(11-84) � I 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 a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS 7 G� Certified copy is hereby furnished. BUILDING `J �JJJ� ADDRESS LOCALITY F Certified copy is filed with the county building inspectionLOCALITY. ' NEAREST - department. �- CROSS ST. Date Applicant NEAREST J�eZl _ DISTRICT NO TYPE PR ¢ESSED BY CROSS ST. yj� -� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. HIGHWAY CIRLE) STATE MAJOR SECOND LOCAL ' NO. OF HLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of SIZE OF LOT / y EXISTING BLDG. I certify that in the performance of the work for which this I o permit is issued,I shall not employ any person in any manner OWNER �2f—/� so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o [2i] � AD DRES t--' Date Applicant TEL t ul d'j _!� Z.r f7� OCCUPANT LOAD o_ NOTICE TO APPLICANT: If, after making this Certificate of CITY "—X- OR o. J 9 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❑ No Spec. Knowl. 0 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- ness NO. OF EXITS and Professions Code,and my license is in full force and effect. s 04 PARK INGSPACES REQ'D PROVIDED License Number Lic. Class y' - //•}/� LIMITED TIME USE Contractor Date v '• DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S g P � SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �� STORIES iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING — Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS p ON LOT AND USE ACICTn'R I hereby affirm that I am exempt from the Contractor's f'i License Law for the following reason (Section 7031.5, Busi- .3 313t v&r` ness and Professions Code): NO. PARKING T EM- I, as owner of the property, will do the work and the SPACES PROVIDED ---? { f structure is not intended or offered for sale (Section TOTAL 227 . 67 7044,Business and Professions Code). n� CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ;X ��'o f I hereby affirm that there is a construction lending agency I_�{�jN- for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name (,eee��yy010 ;{ 'f PROPOSED MAX. OCG. V�'_s I—iJJ tifig Lender's Address 9243 1 AM11"1 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, and hereby authprize representatives of this County to enter TOTAL. FEE X6 ry upon t q-pentiped property for inspection purposes. _ L SEE REVERSE FOR EXPLANATORY LANGUAGE Sig lure of Permittee Date