HomeMy Public PortalAbout9849 VAL ST_Miscellaneous__ 040+KERS'COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I leave a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company BUILDING
FOR APPLICANT
TTTO FILL IN ADDRESS ' I
Certified copy is hereby furnished. wcnRess�C�T/G. ��G ✓/� rJ� �J > LOCALITY
le
El Certified copy is filed with the county building inspection 1 LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST �(// /p DISTRICT NO. GR P TV PE 1PR O
C SSED BY
CROSS ST. 1410 r /1 -)rr (X�� CONST: 1�//
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Ir�� _I Tr
COMPENSATION INSURANCE DESCRIPTION LOT NO. 1 .3 BLOCK 05 MAP`�'rj /�,,G"AY STATE MAJOR SEC D LOCAL
no. (clRcl.e)
NO. OF HLDGS.
(This section need not be completed if the work involved TRACT r 0363 NOW ON LOT USE ZONIE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) t SIZE OF LOT 6o�jog Ei uST
XIsE oR —3
I,
ING BLDG. a
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNERAO
so as to become subject to the Workers' Compensation Laws. `f�� `s 7
] P ■�--f 4/ OCCUPANCY GROUP -
ADDRESS
MAIL
Date Applicant LL,
NOTICE TO APPLICANT: If,after making this Certificate of clrY � eilITvo4' OCCUPANT LOAD D-
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 USE ❑ GEOLOGY INSPECTION ElNo Spec. Knowl. ID
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 P /�l�1��i�>.�D�%
effect. PARKING
SPACES REO�D � PROVIDED
License Number Lic. Class — ll'�� � � �� �
LIMITED TIME USE
Contractor Date �a DATDATE
ElI am exempt from the licensing requirements as I am a FROM: TO!
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bels- EXISTING BLDG. STORIES SIGN TURE
inessaid Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
I&//�&4 W
HOME OWNER-BUILDER 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-
ness and Professions Code): NO. PARKING 2$54.6 A
❑ I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section # o D 0-0 3 Q
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I --:- 8Q50 --
I hereby affirm that there is a construction lending agency o o-o $ Q 5 Q CES
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. :1 20-87
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE Q
above information is correct.I agree to comply with all County ISSUANCE FEE J
ordinances and State laws relating to building construction, '
and hereby authorize representatives of this County to enter TOTAL FEE
upon the e-mentioned �inW�ec�tion prpert purposes.
4— 7 REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date 7