HomeMy Public PortalAbout5332-5334-5336-5338-5340 VILLAGE CIRCLE DR_Miscellaneous__ WOR KERS'COnIPENSAT[ON DECLARATION
CE 875(2 80) MISCELLANEOUS APPLICATION
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' CE 875 u
1 heretiy affirm that 1 have certificate of consent self 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
.535"W�� 11
F1 Certified copy is hereby furnished. BUILDING �� I L�(l�/� / LOCALITY
ADDRESS .r 1 l
❑ Certified copy is filed with the county building inspectionNEAREST
LOCALITY �d Ci CROSS ST.
department. G
Date Applicant NEAREST ��-^ DISTRICT N� G�7777UP TYPE PRO ED BY
CROSS ST. " /, ,33 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL � t J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECO D LOCAL d
NO. OF BLDGS. �`•I NO. (CIRCLE)
(This seCt10R nCCd not be completed if the work involved TRACT r.. NOW ON LOT V USE ZONE FCIAL CONDITIONS 0
by the permit is for one hundred dollars (3100) or less.) USE of //,,
SIZE OF LOT USE BLDG.6nC10
I certify that in the performance of the work for which this I A 0
permit is issued, 1 shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL D e�=�� -4 OCCUPANCY GROUP 3
Date Applicant W
ADDRESS P— sirviEIoG tCL
o
I
NOTICE TO APPLICANT: If, atter making this Certificate of CITY R r card (�, N0- 5,11� ILjZ_ 10 OCCUPANT LOAD
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 USEGEOLOGY INSPECTION
❑ C] No Spec. Knowl.
deemed revoked.
s OCCUPANCY INSPECTIONPanic Devices
LICENSED CONTRACTORS DECLARATION ® _
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and �3I� �� e
�— PARKING
effect. �+ iU� SPACES REO'D PROVIDED
License Number Lic.Class r u1771 If E E LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF /A NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 11%
S. STORIES SI6.T..
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL J
Lic.or Reg.No. Date [�
(foha0
NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
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-
NO. PARKING
netts and Professions Code): G
SPACES PROVIDED 2
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 #1469.g8
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency -I o 980,50
for the performance of the work for which this permit is o 0 0 $a 5 Q
issued(Sec. 3097,Civ.C.).
63
Lender's Name PROPOSED MAX. OCC. 0523-86
Lender's Address PERMIT FEE e
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 02 J O
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorise representatives of this County to enter V
u n th bov�-meentiion�ledlproperty for inspection purposes. SEF.REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date