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Home My Public Portal About6427 SULTANA AVE_Miscellaneous__ i WORKERS'COMPENSATION DECLARATION C�E 875(11-84) M ISCELLANEOUS-APPLICATION I hereby'ffirm: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.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDR635 Certified copy is hereby furnished. BUILDING �� Avg- LOCALI1y�r •ADDRESS /�►� V,K�� •�• I DCertified copy is filed with the county building inspection 'LOCALITY-ry�.,y7 p NEAREST department. Irr �e— /" CROSS ST. Date Applicant NEAREST ` IIPAJDIST�i�O% GRA TYPE / PRM1,7Y jr-RE ST. M CYI/ Y■y`+ CONST.1.// CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /y COMPENSATION INSURANCE DESCRIPTION LOT NO. (� (VBLOCK(J Vee MAP I HIGHWAY STATE MAJOR SECOND -CAL IAC OR'BLDGS. NO. (CIRCLE) (This section need not be completed if the work involved ITRA //7 5/ .. a WON LOT Us ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) // O USE of /(1 .SIZE OF LOT& r EXISTING BLDG 1d re_ • a I certify that in the performance of the work for which this Y o permit is issued,I shall not employ any person in:any'manner :OWNER so as to become subject to the Workers'Compensation Laws. MAILjtt / +/� OCCUPANCY GROUP �� a ADDRESS 4,AtA 7 A/ Q 5L . _ A Ake , I CF.7 Date Applicant //�� TEL, r 'NOTICE TO APPLICANT: If,after making this Certificate of clT p�6r* /� No. �$'1,7 3"� OCCUPANT LOAD C^ '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 DISE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices' E 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 YYY NO.OF EXITS .ness and Professions Code,and my license is in full force and C' effect. /�L/-} '�� `AP#d3AdA K' gARKINPACr%Sr REq'D PROVIDED License Number Lic. Class ��11 7 2� LIMITED TIME USE Contractor Date A0 �C! r7[f I— DATE DATE 0 I am exempt from the licensing requirements as I am a `(T 7 , licensed architect or a registered professional engineer SIZE OF o/` NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG'. STORIES NATURB ol iness and Professions Code). PRESENT USE OR BUILDING F1 NAL APPROVAL Lic.or Reg.No. Date 1. I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's I P_9 28,•2 A License Law for the following reason (Section 7031.5, Busi- ness usiness and Professions Code): NO.PARKING # O o'0 .0'3 0 I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section I o. D 8 Q'5 0 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING aoD8Q5.010: I' 'hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 31 _8 8 issued(Sec.3097,Civ.Q. I Lender's Name PROPOSED MAX. OCC. Lender's Address � I certify that I have read this application and state that the PERMIT. FEE above information is correct.I agree to comply with all County ISSUANCE FEE S ordinances and State laws relating to budding construction, and hereby authorize representatives of this County to enter TOTAL FEE up t e above-mentioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .4 00 , Signature of Perini a Date t i WORKERS'COMPENSATION DECLARATION 76M444 ,4 CE 875 (11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDINGI ,,�� II 4 ADDRESS 1GJ .A Jam' �ia.L`T M. LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAR EST department. 'E'/Y1 �_ d-f' CROS. sT. Date Applicant NEAREST DISTRICT O/ G TYPE / IPRMBY ACROSS ST. M' ,71�fY7/ CONS r.,/ CERTIFICQATE OF EXEMPTION FROM WORKERS' LEGAL �/y S L V I VV COMPENSATION INSURANCE DESCRIPTION LOT NO. �s BLOCK(7 W4 MAP HIGHWAY STATE MAJOR SECOND CAL //(( 9 I�I[y OF BLDGS. ( NO. I (CIRCLE) (This section need not be completed if the work involved :TRA C ' 1/1 S/Q ` 1 VOW ON LOT f US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($.100) or less.) USE F SIZE OF LOT ZQ EX i STOING BLDG df�.UtC / a I certify that in the performance of the work for which this Y��YVV�� permit is issued,I shall not employ any person in any manner OWNER L L) M. SPEARS y so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP i� 04 MAIL % •_ f o Td / p AD DR ESS�j. L .�ir•�� / rl-N `e , U Date Applicant 1J mg �� IEL TEL. R^,-2 1� OCCUPANT LOAD NOTICE TO APPLICANT: If after mak' this Certificate of cIT No. / ` y Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such pIovlsions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. E] ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 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 �I /� effect. /�G f') EI? �� en �7 PARKING SPACES REG'D O PROVIDED License Number Lic. Class ' � � ,eQ �C LIMITED TIME USE Contractor Date fri�rz� / F-r d f � OATH DATE FROMI I am exempt from the licensing requirements as I am a TOI licensed architect or a registered professional engineer SIZE OF •fir Ori NO. OF INSPECTOR s acting in my professional capacity (Section 7051, Blas- EXISTING BLDG. STORIES -NATURE iness and Professions Code). CmV O INAL APPROVAL PRESENT USE OF BUILDING (,(/ Lic.or Reg.No. Date v 2� ,/ I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's -2 9 2 8.2 R License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING # o D o 0 3 U I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section I 0 0 8(15 0 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING . 0 0 8 0.5 0 5 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is o 3 3 1 —8 8 issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCG. Lender's Address I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE S ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upo t e above-mentioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Peri a Date 00 in