HomeMy Public PortalAbout5329 WELLAND AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION E 875 (2-80)4
CMISCELLANEOUS APPLICATION
CE 87
1 Hereby affirm that I have 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.) A AA
Policy No. Company. FOR APPLICANT TO FILL IN BUILDINSG
F1ADDRESS
Certified copy is hereby furnished. BUILDING
r�r/n `` N� Avg LOCALITY
ADDRESS J oC�7
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY 7 ZrL CROSS ST.
Date Applicant NEAREST /� DISTRICT X10. G}jj���ODUP TYPE / 1PROC ED BY
CROSS ST. D L� IL�Gr (�'�/R( Ki^ CONST. - J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L/ (f�
COMPENSATION INSURANCE DESCRIPTION LOT NO. 3Q BLOCK MAP HIGHWAY
NO. F BLDG$. }
NO. (CIRCLE) STATE MAJOR SEC ND LOCAL a
O
(This Section need not be completed if the work involved TRACT2 O NOW ON LOT , USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars (5100) or less.) (�/1
SIZE OF LOT EXISTING BLDG. A I er
USE
of
I certify that in the performance of the work for which this r` O
14/,CL G D� IX
Date U
so as to become subject to the Workers'Compensation Laws. MAIL `' d OCCUPANCY GROUP
Applicant ADDRESS
permit is issued, I shall not employ any person in any manner OwNER 11971 14CE 0411799.0(p 3 eL/fFp �-
L' /� 7 j Q U)
li /, /4I DO-0-1 TEL �J 7 !o Z
NOTICE TO APPLICANT: If, after making this Certificate of cITY L No. 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 USE[:] GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked. Panic D@VIC@S ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 �G4(�
effect. 4r� L'-. Orr PARKING
SPACES REQ'D PROVIDED O
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am al
licensed architect or a registered professional engineer, size OF _ NO. OFINSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. Ix"7 STORIES S NATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL 2 %
Lic.or Reg.No. Date—. �f
$'j R[Erluf /=4 wLI rir
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
Ii
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor'
License Law for the following reason (Section 7031.5, Busi;
ness and Professions Code): NO. PARKING �y,�//1
T/rs94-4IY
EJ19 as owner of the property, will do the work and the SPACES PROVIDED PLL/5 C//��
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING t1
CONSTRUCTION LENDING AGENCY S r/t�(�L/ri /mid PW
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 4 1 9.6 A
issued(Sec. 3097,Civ.C.). {�
Lender's Name a PROPOSED MAX. OCC. # • o • • 3 O
Lender's Address PERMIT FEE -1 ;tI II • a 8(1 5 O
1 certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE o 0 0 $Q. �
ordinances and State laws relating to building construction, ry 1 0- O2
and hereby authorize representatives of this County to enter TOTAL FEE (/
upon tl ve-igentioned p operty for inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date