HomeMy Public PortalAbout9002 WOOLLEY ST_Miscellaneous__ �►'"'` 0\� y ' CE 875(11-84) MISCELLANEOUS APPLICATION
ry COMPENSATION DECLARATION 76M444
WURKERS'COM
1 "j�.
I Ngreb,..affirm that I have a 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS / o;)- wdd Q LOCALITY
DCertified copy is filed with the county building inspection LOCALITY -�}''� NEAREST
department. 1 1 CROSS ST.
Date Applicant NEAREST / DISTRICT NO. Gg¢¢tttfffyyy�CY_P.EP
PRO SED BY
CROSS ST. /IV �JCERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I`
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SEC D LOCAL
NO. OF BLD GS. e2
NO. (CIRCLE)
(This Section need not be completed if the work involved TRACT NOW ON LOT !— US ONE SPECIAL CONDITIONS
by'-the permit is for one hundred dollars ($100) or less.) USE OF l
SIZE OF LOT. EXISTING BLDG.
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 OWNER
so as to become subject to the Workers' Compensation Laws. MAIL s OCCUPANCY GROUP o
ADDRESS
Date Applicant u,
NOTICE TO APPLICANT: If, after making this Certificate of CITY C ITuo� OCCUPANT LOAD a
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- All FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY 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 Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and 1 I , ,`
effect. �� A3 PARKING REq'D PRO��O6D
'
License Number SPACES Lic. Class W LIMITED TIME USE
Contractor Date -?fbO Ro4eS DATE DATE
ElI am exempt from the licensing requirements as I am a T
FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. . Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 9 2 4 0 A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's # o 0'0 0 3.0
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 o 0 08 Q 5 0 60
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
PROPOSED USE OF BUILDING 03,24-88
CONSTRUCTION LENDING AGENCY
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
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
ordinances and State laws relating to building construction,
and her by authorize representatives of this County toe ter TOTAL FEE
upon t above mentiono ori ction p rpos
Cy SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat