HomeMy Public PortalAbout5026 DOREEN AVE_Miscellaneous_10/18/1991_IWORICE) S'COMPENSATION DECLARATION 8 a
CE (t t-84) M ISCELL-ANEOUS APPLICATION {�
CE 87LJ
I hereby 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. C.).
Policy No. Company
FOR APPLICANT TO FILL IN
BDDRESE �-J�aV KA�¢�olir•i
❑Certified copy is hereby furnished.
AO DR ESS �q
���D ?
lt-Yi�tTt6.-Ge,
❑ Certified copy is filed with the county building inspection
.,JoL£n_riLOC
LOCAL I-7ZA 4. /�-�
NEAREST
department.
�Ci/7 F� V -
LRGss sr.
Date Applicant
NEAREST r /J
CROSS ST.
DISTRICT NdO.GRUP
I /�J� -O 3
TYPE CESSED BY
(CONST.v
CERTIFICATE OF EXEMPTION FROM WORKERS'
LEGAL
COMPENSATION INSURANCE
DESCRIPTION
LOT NO. BLOLK
mAn HIGHWAY STATE MAJOR SECOND LOCAL
NC. (CIRCLE)
(This S2ChOn need not be completed If the WOIk involved
TRACT /f/!
// w �,4
NO. OF BLDGS.
NOW ON LOT
UEE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
•'
SIZE OF LOT �6 Yafo
use OF
EXISTING BLOG��6
/
I certify that in the performance of the work for which this
is issued, I shall not employ any in any manner
6j, R� I
o
`�
permit person
OWNER 1W. eAz&
so as to become subject to the Workers' Compensation Laws.
MAIL _ / I
OCCUPANCY GROUP
wDDREss,,ro,L.d
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
�/ TEL.
c 0119' `.1%/ NO. �>/ ���j OCCUPANT LOAD
l�� C.17/
W
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.
Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
occu rwn cv INSPECTION
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
effect
`
/T�� A p 9 -re)
PARKING RED
REQ
PROVIDED
t# i�'-e I Q S
5'
S PACES
License Number Lie. Class
Ct 7h'� �'r
LIMITED TIME USE
Contractor Date
DATE DATE
❑ I am exempt from the licensing requirements as I am a
FRom: T�
•S
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
SIZE OFR
EXISTING SLOG. IOIV �/ STORIES
_ S GNA RE
iness and Professions Code).
+
(FINAL
PRESENT USE OF BUILDING
APPROVAL
Lie. 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-
ness Professions Code):INO. PwRK09G
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). (^
CONSTRUCTION LENDING AGENCY I PROPOSED USE OF BUILOIRO
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit n'
issued (Sec. 3097, Civ. Q.
Lender's NamP -
PROPOSED MAX. OCC.
Lender's Addre,,�
I certify that I have read this application and state that the I PERMIT FEE
above information is correct. I agree to comply with all County I ISSUANCE FEE
Ordinances and State laws relating to building construction,
and hereby authorize re resentatives of this County to enter I TOTAL FEE
u��porrryyy,,,t1���e ;ignm,re
ovyyIn d property for inspection p rpose . c
y - A;7,9/ SEE REVERSE FOR EXPLANATORY LANGUAGE
/,/ of Permittee — Date
z -im im D A
D
r Ca Ca m
0000 A m
D 1m 1A < A D
T CD CD a a
T
mm
mA m y m
< < A m
D m v 3 O
D
r O A
O
z < <
w m
0
v 0 O
m
n
1
O�
3J
� O
D
m �s
4vm
� OZ
0m
Zm
DO
co
CO
6
MMM
my
_ Z