HomeMy Public PortalAbout5302 ZADELL AVE_Miscellaneous_2/17/1994_ WORKER4'Q@MPENSATIONDECLARATION CE 76M444
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDINE
ADDRSSG 5�(3c� !- G.[+��i1
Certified copy is hereby furnished. BUILDING 5300 � LOCALITY to A-10 G'+
ADDRESS
tJ
Certified copy is filed with the county building inspection LOCALITY CROSS ST.
department. �C�V6) I
Date Applicant NEAREST DISTRICT NO. GROUP TYPE P O S D BY
CROSS ST. Q 11 �,D� ��-� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY gTATE MAJO SEC D OCAL
NO. (CIRCLE)
NO. OF HLD GS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) Q
USE OF
SIZE OF LOT EXISTING BLDG. ' d
I certify that in the performance of the work for which this• o
W.
permit is issued,I shall not employ any person in any manner owNER �) T F—h V_-k C W Pioy
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS u�-30oL zaae[iAve - LL��J
Date Applicant LLI
NOTICE TO APPLICANT: If,after making this Certificate of CITY l nTio` ��� 7OCCUPANT LOAD z
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code,you must forth- v APPLICATION FOR EXIT HARDWARE:
with comply with such provisions. or this permit shall be S TRAILER USE E] GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION pk
OCCUPANCY INSPECTIO Panic Devices
I hereby affirm that I am licensed under provisions of Chapter V SAFETY PERMIT
9 (commencing with Section 7000) of Division 3 of the Busi-
ness
❑ (LIST ITEMS BELOW) No.of EXITS
and Professions Code,and my license is in full force and
effect. Wft[ NrCbm - O PARKING
SPACES REQ'D PROVIDED
License Number Lic. Class 59 LIMITED TIME USE
Contractor DateR DATE DATE
❑ I am exempt from the licensing requirements as I am a [uVYb Iy1 YVY1it— 9�0'F
FROM: To:
licensed architect or a registered professional engineer s,zE of NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
inessand Professions Code). FINAL APPROVAL 'Q
PRESENT USE OF BUILDING
Lic.or Reg.No. .Date r
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
.usiness and Professions Code): NO. PARKING p ;
I, as owner of the property, will do the work and the SPACES PROVIDED 30
structure is not intended or offered' for sale .(Section 'r¢}!_:(_.
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 3'SL X39'`4°
I Hereby affirm that there is a construction lending agency ITEMS
•for the performance of the work for which this permit is TOTAL 234.45
issued(Sec.3097,Civ.C.).
Lender's Name CHECK=K '%�� c.
PROPOSED MAX. OCC.
Lender's Address CHANGE
GE
I certify that I have read this application and state that the PERMIT FEE '2OEj .US
above information is correct.I agree to comply with all County ISSUANCE FEE Oro-
ordinances and State laws re ting to building construction,
and a by authorize represe` atives of this County to enter TOTAL FEE 1313001-00131 2/171"94i
e above-mentioned p rty for inspection purposes. . j 9
SEE REVERSE FOR EXPLANATORY LANGUAGE 40
Signature of Perml ee Date
1
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