HomeMy Public PortalAbout5721 OAK AVE_Miscellaneous_12/2/1987_- 11UktERS' COMPENSATION DECLARATION
I hP„eby 4dtlrm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. Q.
Policy No. Company
Certified copy is hereby furnished.
❑Certified copy is filed with the county building inspection
department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number Lic. Class
Contractor Dat
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic. or Reg. No. Data
IIOME OWNER -BUILDER DECLARATION
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):
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).
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. C.).
Lender's NamP
Lender's Addre«
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby uthorize representa'les of this County to enter
upon the ove-mentioned pro y for i pection purposes.
Signafure DflIermit a fate
76N44'
CE 875 (71-84) MISCELLANEOUS APPLICATION
COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILD
5/ �,
ADDRESS /� • O� LOCALITY
/, NEAREST
LOCALITY lll""���....•..
T/ `/ CROSS ST.
NEAREST ./ ' DISTRICT O GROUP TY iPROCE ED BY
CROSS ST, y R CONSL'/
LEGAL( IJ Y
DESCRIPTION ILOT NO. IBLOCK n q'NWAY STATE MAJOR SECONdLOCALI
NO. OF SLOGS:L OF ZONEISPECIACLRCONDITIONS
TRACT /'')/,y NOW ON LOT
r l6 �t / // ✓ / USE OF
SIZE OF LrO''T.. USE
EXISTING BLDG.
OWNER K.T4LI��--Z ) L���SZ2�M I I
MAIL I�7 _ ��/ OCCUPANCY GROUP IIL�JII
AOORESS�5 S �D 3t -N-D ,
CITY A% ��7 / NO a,�s'-�Z9Z OCCUPANT LOAD
APPLICAIfION FOR EXIT HARDWARE:
TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
OCCUPANCY INSPECTION ❑ Panic Devices ❑
SAFETY PERMIT ❑ (LIST ITEMS BELOW)
//���j NO. OF EXITS
CJ Tj/y� j(j/P/G///f"Lr t %J� IPARKI.. REO'D I PROVIDEp
SPACE
SPACE S
Can f/ I LIMITED TIME USE
TOTALFEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
S-63-7
30
(a01sD
INSPECTOR'S
/SIGH URE/
DATE
SIZE OFIST
EXISTING SLOG.
j FgOM1
OF /
✓ �//J
PRESENT USE OF BUILDING
/,STORIES
Fi/{�TiT/ JS
FINAL APPROVAL
NO. OF EXISTING BUILDINGS
ON LOT AND USE
NO. PARKING
SPACER PARKING
J�
4- Lotioj-
PROPOSED USE OF
BUILDINGC/�Y./
bpi
PROPOSED MAX. Dec.
PERMIT FEE
ISSUANCE FEE
TOTALFEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
S-63-7
30
(a01sD
INSPECTOR'S
/SIGH URE/
i,.,INSPE'CTOR�S NOTES 'OWNER -BUILDER DECLARATION
j • �`, ± ,, '. . t. ' j I heteby affirm that I am exempt from.,.the �oi)tract%ris
Licenie -Law for the following reason (Section 7031:5,;
-......... Busin-ss and Professions' Code): Arlt► e1tY:or c6unty -.
'• '
which -.requires a. permit to construct, alteir,.-improVe.
INSPECTOR'S '
APPROVALS i, DATE SIGNATURE demolish, a repair any structure, privy to its.issuan e; -•j
also requires the applicant for such per•nrit<Arfile,_a-';
TRAILER USE ,. signed Slatetr1er11 that Ire is licenced pursuant; t0...the
provisions of the Contractor's License Law lia 11 r-.9..-
r .: t�,..l, g
SAFETY PERMIT . i � , - (ca)trrnencing with Section 7000) of Division 3 of the,
TEMPORARY Business and Professions Code) or drat he is exempt
,, .;•
STRUCTURE••APPROV-ED therefr•onz and the basis for••Yhe�alleged etenrpliwr: Any
TE U�O•R'A'R`l`' ' "� 4-'�tt' violation of Sectioii 7031.51b anyapphcatit fora permit
STRUCTURE --REMOVED -;. +:'',
f;,� -m. subj�cts.the applicant to a civil, per(alty of jrot,tt?ore tl.;a�r�
fiveihundred dollars (S56,4)*. jirr=-,Ai vrt
• ..; t ' _ '� t; (;, .}�, `_'.�.� ti.. C7 I, as owner of the property will do the work,. and
the structure is not intended or, offered for sale.
(Sec:' 7044. business and. P_rofessioirs; Code: "'Tire Coit-
F,INAL APPROVAL„�• z
tractor's License Law does not apply 'to an owner bf
/ property . who builds or inupro +es,tlrqteon, and who does . A
G' ,•. ;:� �,♦, . 1 b ti ,`' : ,tt . 4 sucht�wor� lrirrrself provided thati...suclr:,.irrtprovenrents..,
are.; riot. • untended or ' o#fg ed : for„sale. If,' r Never,-.t(le
7 ,... ;,. . "...... _build('ng, or • improvement -'!s so1do:tivitlrin, one • year'„of')
coriipletion;:- the. owner -builder- will:. Irarre4 tlre,' bujder!
of -proving' that he did Trot build or improve fdr. the
purpose of sale.)
' I am exempt under Sec.
B & P.C. for this reason
r �
`. Date
Owner
INSkdTOR'S NOTES 'i'� ` `', jl-N., J
i
t