HomeMy Public PortalAbout9855 VAL ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(1,1-84) MISCELLANEOUS APPLICATION
I heieby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.Q. ,
Policy No. Company FOR APPLICANT TO FILL IN •UILDING
DRESS -
Certified copy is hereby furnished. VOC
NG -`1 l_'`� Q C J
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0 Certified copy is filed with the county building inspectionNEAREST
department. ITY L . lit G
Date Applicant EAREST �.. DISTRICT NO, iGRO/ TYPE PROCESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' Ross GAL `� r C� U ' K core
LEGAL n L
COMPENSATION INSURANCE DESCRIPTION LOT NO. [� BLOCK MAP HIGHWAY STATE MAJOR SEC,-#I- LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(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.) I USE OF
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 ����✓ ;� y
so as to become subject to the Workers ompensation Laws. OCCUPANCY GROUP 3 �
Date -' r ' Applicant!!'!,G '{/1TF6G�id' �J ' '�' °oREss
U
W
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of ITY NO. y
Exemption, you should become subject to the Workersz
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: _
with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ 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 Busl NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. �'ES% (�'��4L /% PARKING
SPACES REq'D PROVIDED
License Number Lic. Class6CA '- 2 - - �'� - 0 i�Od(J
,• d y LIMITED TIME USE
Contractor Date
/-"N, Gv--�, � � DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM: TO: '
licensed architect or a registered professional engineer SIZE OF NO.OF J INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES L/ SIG ATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING _
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
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is ,--, {-� K-, _ (.,,1 3-. r_-.i
issued(Sec.3097,Civ.Q. per e-iv/p£ q, �
Lender's Name ,^, u
PROPOSED MAX. OCC. I L iC (—' 1•-'• �I F+
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
I:r+
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
y tl a ab e-men,�oned�property-for inspection purposes. I-- Cli SEE REVERSE FOR EXPLANATORY LANGUAGEr:Z
r'
Signa / I t• rs.l l'.Cl
re of Permittee Date F•. 1-'1 I,J r_!