HomeMy Public PortalAbout6361 TRELAWNEY AVE_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION CE 8784(280) MISCELLANEOUS APPLICATION
1 hereby aft'rm 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 CompanyFOR APPLICANT TO FILL IN BADDRESS 63,4
UILDING❑ Cert riled copy B hereby furnished au uDlnG
ADDR¢aa Locwurr
Certified copy E filed with the county building inspectionrs N¢AR¢aT
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department LOCALITY ROSS ST
Date Applicant NEAREST DISTRICT Nyq O„„OU TY"
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¢D BY cwoLEGA 5r ,fq n_ � Conan/
CLRTII ICATL OF EXEMPTION FROM WORKERS Leau V O v
COMPENSATION INSURANCE DESCRIPTION Lor No BLOCK IDNRw
Mw NO FCIFCLS) STATE MAJOR SEc o LOCAL y
(Thu section need not be completed if the work mvolved NO OF LOIS ua P ZONE a.HCIAL CONDITIONS
TRACT NOW ON LOT
by the permit Is for one hundred dollars (5100) or leu) use of
1 certifythat m the
SIZE of LOT E%IaTINO BLDG — cc
performance of the work for which this 0
permit is Issued I shall not employ any person In any manner ow.ERW I—
so as to become subject to the Workers Compensation Laws MAIL P p f7 S OCCUPANCY GROUP W
ADDRESS 1
Date Applicant 2
NOTICE TO APPLICANT If after making this Certificate of CITY
TE
OCCUPANT LOAD
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 provisions or this permit shall be TRAILER USQGEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO or EXITS
9 (commencing with Section 7000) of Division 3 of the Busi
nest and Professions Code and my license Is In full force andkyspSl-y ING Pw RK
effect REO D O PROV10 an
^ SPACES
License Number Lic Class A
LIMITED TIME USE
Contractor Date CATS DATE
❑ ROM ro
1 am exempt from the licensingregiregistered
requirements as I am a
licensed architect or a registered professional engineer a6E of No OP INar¢cTOR'S
acting m my professional capacity (Section 7051, Bus- exlannG ¢LDC aro NO 1. E)ONwruRE
mess and Profe ons Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS
0 LOT AND USE
I hereby affirm that 1 am exempt from the Contractors j
License Law for the following reason (Section 7031 5 Bust
ness and Professions Code) No PARKING
SPACES PROVIDED
❑ 1 as owner of the property will do the work and the
structure Is not Intended or offered for sale (Section
7044 Business and Professions Code) PROPOSED USE OF BUILDING ;245665A z
CONSTRUCTION LLN DING AGENCY
# • • • 0 ,30
1 hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is I S - 8Q5'0
Issued (Sec 3097 Civ C) J
Lender s Name 8 Q 40 is
PROPOSED MAX OCC • � �
Lender s Address PERMIT FEE ')31L 0 5 0 1 t.-86
1 certify that 1 have read this application and state that the
above Information Is correct I agree to comply with all County ISSUANCE FEE 149'S__0
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authorize representatives of this Count) to enter
upon he above mentioned property for Inspect[ n P1170"s SEE REVERSE FOR EXPLANATORY LANGUAGE
ae
Signature of Permittee Date