HomeMy Public PortalAbout5610 WELLAND AVE_Miscellaneous__ WORKERSCOMPENSATION DECLARATION
•:;� k. CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm ahave a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure'-,or a certificicatee of Workers'Compensation Insurance,e,or -
a certff, copy thereof(Sec.3800,Lab.C`.).
Policy Nb Company //FOR APPLICANT TO FILL IN ADDRESS,/i
/Q— ��,20 Gf/✓
Certified copy is hereby furnished. nnoRessSC/d .�G�a' �trtl L,gNDq VZ LOCALITY
Certified copy is filed with the county building inspectionLOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST ( L O�I, DISTRICT�NIO. G OU TYPE CONST. PR CESSED BY
CROSS ST. (r r( 6/� �7 P 1/ f
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VtJ �/
COMPENSATION INSURANCE DESCRIPTION LOT NO. HLO CK MMAOP HIGH g) STATE MAJOR SECOND LOCAL
NO. OF BLDGS. /
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONESP "
ECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE OF
SIZE OF LOT EXISTING BLDG. �7 �
I certify that in the performance of the work for which this 116-01-1O } o
permit is issued,I shall not.employ any person in any manner OWNER1[ VP 14X1 f d(J17_W-C—A) GlyZ-^J• / CD
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP _
J=
Date Applicant �f��� �
ADDRESS LVp 1—•
L V�
NOTICE TO APPLICANT: If, afte making this Certificate of CITY L A48A/� rNO J(?/f5-)-F —]qq OCCUPANT LOA
Exemption, you should becwm subject to the Workers' APPLICATION FOR EXIT HARDWARE: _
Compensation provisions of the abor Code,you must forth-
with comply with such provis ns or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec Howl.
LICENSED CONTRA TORS DECLARATION OCCUPANCY INSPECTION ❑ Panic vices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM1 (LIST ITEMS BELOW)
9 (commencing with Section 000) of Division 3 of the Busi- ���i���iVVVVII������ NO. 0/
EXITS
ness and Professions Code,a d my license is in full force and
effect. m bF PARKING R q•D PROVIDED
SPACES
License Number Lic. Class - RbC IIS 7r
LIMITED TIME USE
Contractor Date DATE DATE
El I am exempt fro the licensing requirements as I am a
FROM: O:
licensed architec or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my pr fessional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ^ SIGNATURE
iness and Profess• ns Code). ^
A nn 7 � ��L FINAL APPROVAL
PRESENT USE OF BUILDING !7Q t-I�-" K
Lic.or Reg.No. Date
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- l r ;
ness and Professions Code): NO. PARKING A' 10—
'F� I, as owner off'the property, will do the work and the SPACES PROVIDED
I 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
issued(Sec. 3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State 1 ws relating to building construction, ' e_1
and hereby authorizer resentativ s of this County to enter TOTAL FEE
'upon t11�ab v mention propert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
3 .0
Si ature Permittee Date