HomeMy WebLinkAbout1493A (8)WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 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 fled 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 (5100) 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 �' rke s CotrypFnsation Laws.
Date.///��Applicant
NO CE TO A LICANT: If, after making this Ce 'cafe of
Exemption, you should become subject to the 6'orkers'
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 Date
❑ 1 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-
inessand Professions Code).
Lic. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
1, 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 (Sea 3097, Civ. Q.
Lender's Name
Lender's Address
1 certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
u the above-mentioned property for inspection pl rpose.
p/�—_ _ O
Signature of Permittee Da c
CE 875 (11841 MISCELLANEOUS APPLICATION
CE 875
COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
ADDRESS !'
ADDRESS
ADDRESS ✓l
LOCALITY Mol �
J �/crso933TT.
AR ES
NEAREST C -•/
CROSS ST. ��`
DISTRICT NO. GROVP TYPE F.....3.. BY
CONST.
yV
I Q Gtr
LEGAL
DESCRIPTION LOT NO. BLOCK
NO. OF BLDGS.
MAv
(eoiw ViAY e) STATE MAJOR SECOND LOCAL
_
TRACT NOW ON LOT
VSE I NE ECTAL CONDITION.
OF
SIZE 0P LOT EXISTING BLDG.
E
OWNER A W k ellfZS
OCCUPANCY GROUP
MAIL' I ` _
ADORES ' IC 'I S .c,tiNC
TEL' 7/
CITY R KR NO,
OCCUPANT LOAD
17/ APPLICATION FOR
EXIT HARDWARE:
TRAILER USE ❑ GEOL GY INSPECTION ❑
No Spec. Knowl.
Panic Devices
OCCUPANCY INSPECTION
SAFETY PERMIT ❑ (LIST ITEMS BELOW)
NO. OF EXITS
/
PARKING
REO'D PROVIDE.
SPACES
LIMITED TIME USE
OD.T�
PAT•
16 Z J1
31ZE OF OP
INSPECTOR'S
sO.
-STING BLDG, TORIES
SIGNATURE
PRESENT USE OF BUILDING S' IZ
FINAL APPROVAL 111 6�-0 7 yY�y/
6 / �6�lY
NO. OF EXISTING BUILDINGS
r
ON LOT AND USE
149.3A
NO. PARKING
}y�
• • • • 30
SPACES PROVIDED
fi
j • •80.50
PROPOSED USE Or BUILDING
• • -8(150u'
09,11-87
PROPOSED MAX. OCC.
PERMIT FEE
ISSUANCE FEE G 70
TOTAL FEE 10 -
SEE REVERSE FOR EXPLANATORY LANGUAGE
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