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HomeMy Public PortalAbout9731 WOOLLEY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION CE 875(2-SO) iby affirm that I have certificate of consent tself; COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,e,or� a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS I " ❑ Certified copy is hereby furnished. FRess , LOCALITY ❑ Certified copy is filed with the county building inspection NEAREST j department. LOCALITY e f CROSS ST. Date Applicant NEAREST DISTRICT N GR TYPE P SSED BY CROSS ST. C?r , 0� / CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL l DESCR'I PTI ON LOT NO. BLOCK MAFG�J RIGNWAY' } COMPENSATION INSURANCE NQ. ""VO (CIRCLE) STATE MAJOR ECOND LOCAL NO. OF SLOGS. C (This section need not be completed if the work involved TRACT NOW ON LOT � USE Z NESPECIAL CONDITIONS Q by the permit is for one hundred dollars ($100) or less.)' SE OF UI I SIZE OF LOT EXISTING BLDG. cc 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 G Yo l.. so as to become subject to the Workers'Compensation Laws., MAIL OCCUPANCY GROUP W ADDRESS 3/�� oo���- a. Date Applicant V) NOTICE TO APPLICANT: If, after making this Certificate of' CITY* ` TEL 1 — OCCUPANT LOAD Exemption, you should become subject to the Workers' IF 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 deemed revoked. . ❑ C] No Spec. Kriowl. ❑ OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS a 9 (commencing with Section 7000)of Division 3 of the Busi-' ness and Professions Code, and my license is in full force and)f PARKING. effect. •SPACES REQ'D E:= PROVIDED q � � License Number Lic.Class I V! LIMITED TIME USE Contractor Date DATE DATE ❑ ) FROM: TO: I am exempt from the licensing requirements as I am aI licensed architect or a registered professional engineer] SIZE OF NO. OF I ` C VINs c acting In my professional capacity (Section 7051, Bus-1 EXISTING BLDG. 'L�' STORIES gj �S1040ATURR Iness and Professions Code). PRESENT USE OF BUILDING ,(ir FINAL/OgfROVAL Lic.or Reg.No. Date ISTING BUILDINGS HOME OWNER-BUILDER DECLARATION NO.OF EX ON LOT AND USE 1 I hereby affirm that- I am exempt from the Contractor's 11 License Law for the following reason (Section 7031.5, Busi-1 ness and Professions Code): NO. PARKING SPACES PROVIDED ❑ I, 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). I PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I I hereby affirm that there is a construction lending agency fpr the performance of the work for which this permit is 114 1 2 3;A issued(Sec.3097,Civ.C.). f 0 3 Q Lender's Name PROPOSED MAX.OCC. o D o�o Lender's Address PERMIT FEE 2 D - 80.50 I certify that I have rdad this application and state that the ISSUANCE FEEG o D 8 0.5 0above information is correct.I agree to comply with all County © I, ordinances and State laws relating to building construction„ TOE TAL FEJ C7 and hereby authorize representatives of this County to enter 8 1 —83 upon thea v?entio d roperty- inspec niurpo 5• SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee. • Date