HomeMy Public PortalAbout5336 ALESSANDRO AVE_Miscellaneous__ k ,
WgxKERS COMPENSATION DECLARATION
CE 875 (11 84) MISCELLANEOUS APPLICATION
�- CE 875
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 BUILDING
ADDRESS (O
Certified copy is hereby furnished ADDRESS 3 s �� LOCALITY I ,
❑ Certified copy is filed with the county building inspection LOCALITY _ L= cRoss sr y
department
Date Applicant NEAREST DISTRICT NO GFFF���QQQUP TYPE IPRO�91ED BY
CROSS ST L/ /[/� CONST /
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL ` �T, V
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
rvG (CIRCLE) STATE MAJOR SE ND LOCAL
NO OF BLDG3
(This section need not be completed if the work Involved TRACT iSb10 i61n1 A 2 NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) use SIZE OF LOT EXISTING BLDG OF
I d
I certify that in the performance of the work for which this o
permit is issued I shall not employ any person in any manner OWNER �/ Q y
so as to become subject to the Workers Compensation Laws MAIL _z OCCUPANCY GROUP �� o
ADDRESS ✓ S L,
Date Applicant `S
W
NOTICE TO APPLICANT If after making this Certificate of clrY _ NOL 2 "�3 2 ' OCCUPANT LOAD
Exemption you should become subject to the Workers APPLI ATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be TRAILER USET
E
Y GEOLOGINSPECTION ❑
❑ E] No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN3P6CTION4 Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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 (,(/ - ���5 IPA PARKING REQ D PROVIDED
SPACES
License Number Lie Class + ' rn' }/� LIMITED TIME USE
Contractor Date S N 3 r' ` DATE DATE
r / b $S PROM TO
I am exempt from the licensing requirements as I am a (rj'
licensed architect or a registered professional engineer SIZE OF No OF INSPECTOR S
acting in my professional capacity (Section 7051 Bus EXISTING BLDG STORIES IGNATURE
mess and Professions Code)
PRESENT USE OF BUILDING FINAL APPROVAL � 7
Lie or Reg No Date
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS yy
ON LOT AND USE Z / / �O A
I hereby affirm that I am exempt from the Contractors �7�7 Z
License Law for the following reason (Section 7031 5 Busi # • e e • 30
ness and Professions Code) NO PARKING
0 I as owner of the property will do the work and the SPACES PROVIDED - a 8 Q 5 O
structure is not intended or offered for sale (Section a a 8 a 5 O 5
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING ) 8.24-87
I hereby affirm that there is a construction lending agency I
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCC
Lender s Address
PERMIT FEE I
I certify that I have read this application and state that the n
above information is correct I agree to comply with all County ISSUANCE FEE /O
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above mention prope for inspection purposes
�— 24 L v�
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permiteee Date