HomeMy Public PortalAbout4809 ALESSANDRO AVE_Miscellaneous__ ERS COMPENSATION DECLARATION
CE 875 (11 84) MISCELLANEOUS APPLICATION
CE 675
a firm that I Have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
in or a certificate of Workers Compensation Insurance or
a led copy thereof(Sec 3800 Lab C)
Polk No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS (17
Certified copy is hereby furnishedLOCALITY
BUILDING 0
ADDRESS _
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department Tom' L„ cRoss sr
Date Applicant NEAREST DISTRI��jj GR UP TYPE JJJ PROC ED BY
CROSS ST (,! ,/� �` CONS
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL ✓ v
COMPENSATION INSURANCE DESCRIPTION LOT NO / BLOCK MAP HIGHWAY STATE MAJOR SECO LOCAL
NO (CIRCLE)
NO OF BLDGS
(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) usE of ( /
SIZE OF LOT EXISTING BLDG ��/6
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
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP
ADDRESS 0 '� 0 U
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of clrr C,T� TEL
. ��'25 OCCUPANT LOAD N
Exemption you should become subject to the Workers APPLIC ION FOR EXIT HARDWARE z
Compensation provisions of the Labor Code you must forth
With comply With such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
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 7 .r C( �CI'Y PARKING REQ D PROVIDED
SPACES
License Number Lie Class lee ,
LIMITED TIME USE
Contractor Date DATE DATE
0 1 am exempt from the licensing requirements as I am a 13 X
licensed architect or a registered professional engineer slzE OF ND OF INSPECTOR s
acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES
ROM TO SIGNATURE
iness and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING �
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 Contractors
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING
0 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 PROPOSED USE of BUILDING y � ti , '
28997A
# eOe030
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is -I e a 8'Q rJ 0
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC �
Lender s Address 71
y t
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE ^�
ordinances and State laws relating to building construction
and hereby uthorize repres tives of this County to enter TOTAL FEE
upon the ove men one ro rty f r inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
of Krmittee Date