HomeMy Public PortalAbout9722 WOOLLEY ST_Miscellaneous__ 7FWORfERS'COMPENSATION DECLARATION 76M444
CE 875(11-84) MISCELLANEOUS APPLICATION {�
I hereby-a firm that I have a certificate of consent to self ® COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION (�
insti4, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BU ILOING P
ADDRESS71,2
D
Certified copy is hereby furnished. wcnRES � &)COZZe M 1 /7� i
LOCALITY
FICertified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST pp ter' �Lv� DISTRICT O. G$$$ UP TYPE PRO ESSED BY
CROSS ST. `m IG /)f �J CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �P.rs•L vit( (� J V
COMPENSATION INSURANCE DESCRIPTION LOT NO. 1'i.Z Blocx Lp-� MAP HIGHWAY STATE MAJOR sEco D LOCAL
C NO.OF SLOGS. NO. (CIRCLE)
(This section need not be completed if the work involved TRACT S6/ NOW ON LOT US ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) / �, us9 OF
SIZE OF LOT«YY/ x/st' EXISTING BLDG. d
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 m B
so as to become subject to the Workers' Compensation Laws. MAIL I OCCUPANCY GROUP' a
Date Applicant ADORES e v/7" Z3
TEL LLI
OCCUPANT LOAD �-
NOTICE TO APPLICANT: If,after making this Certificate of CITY No.
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
With comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
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 L �
effect. PARKING REQ D PROVIDED
SPACES
License Number Lie. Class Raaln `! NSQ J=__r LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer slzE ofNO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL jr-2;7—�
Lie.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).' A31 (I.•1 A
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 90.0 o .03Q .
I hereby affirm that there is a construction lending agency i•° ° $•650
for the performance of the work for which this permit is o'o o $Q 5
issued(Sec.3097,Civ.Q.
05
Lender's Name
PROPOSED MAX. OCG. 0526-- 87
Lender's Address U
PERMIT FEE
I certify that I have read this application and state that the
above information Is t.I agree to comply with all County ISSUANCE FEE
ordinances and Sta law relating to building construction,
ereby author' a rep sentatives of this County to enter TOTAL FEE
upon he above-men t a props or'n ection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat of Pern#ee Date