HomeMy Public PortalAbout5846 ALESSANDRO AVE_Miscellaneous__ WL?RKERF4 COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS A P P LjC A T I O N
CE 875
I herebyor certificate
that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
FICertified copy is hereby furnished. BUILDING _
ADDRESS LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. E I^�t.E t—(`/ CROSS sT.
Date Applicant NEARESTGG JL DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. J V t,3Ik V
CONST.1 /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATIOI�INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY //
NO. (CIRCLE) STATE MAJOR SECOv D LOCAL
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 huj dyed dollars ($100) or less.) SIZE OF LOT USE OF
EXISTING BLDG.
I certify that in the performance of the work for which thisV�Va
permit is issued, I shall not employ any person in any manner OWNER ,1
so as to become subject to the Workers' Compensation Laws. MAIL ��ti IAN ` �W ��� OCCUPANCY GROUP _ �
ADDRESS
DateApplican C-3
NOTICE TO APPLICANT: I , after making this Certificate of CITY Q,C���� cj1Op� NO� 's -yy7• �- Iq7, OCCUPANT LOAD N
Exemption, you shouldb come subject to the Workers' z
Compensation provisions o the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: _
with comply with such rovisions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CON ACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I a licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELow)
9 (commencing with Se ion 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Co e,and my license is in full force and fir!
effect. Y PARKING REQ'D PROVIDED
' 1 SPACES
License Number Lic. Class �R#_ I O N S v s
ITED TIME USE
Contractor Date DAT DATE
FROM: TO:
I amI
pt fr m the licensing requirements as I am a
licenschit t or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
actinmy rofessional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and sionsCode). \ 1 �N j FINAL APPROVAL
PRESENT USE OF BUILDING V
Lic.or ReDate �j
_s— F
HER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby that I am exempt from the Contractor's
License Lthe following reason (Section 7031.5, Busi ; i_,i
ness and Psions Code): NO. PARKING
I, asr of the property, will do the work and the SPACES PROVIDED !,\ �Ct, } J.
STS y3'Ti
strucis not intended or offered for sale (Section O �\
7044ness and Professions Code). � Q\
STRUCTION LENDING AGENCY PROPOSED usE of BUILDING E7 f}I Z 1
I'liereby 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 Name
t PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon thea ve-mentio d pro rt for inspection purposes.
9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date