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HomeMy Public PortalAbout5848 ALESSANDRO AVE_Miscellaneous__ I «ORkERS COMPENSATION DLCL%RAT10h CE 875 (11 84) MISCELLANEOUS APPLICATION �t CE 875 I~ I hereby affirm that I have a certificate of consent to self ' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a Lertifcate of Workers Compensation Insurance or 1�I a certified copy thereof(Sec 3800 Lab C) BUILDING �J Policy No Company FOR APPLICANT TO FILL IN ND DRESS Certified copy is hereby furnishedp D BUILDING i/�y / �,� 5 ©� 0C LITY A ADD. 7"O c--e� I department i opv is filed with the county building inspection X LOCALITY NEAR EST ROSS ST Date Applicant NEAREST DISTRICT NO GROUP TYPE CESSED BY CROSS ST �4✓ CONST F CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSLRA\CE DESCRIPTION LOT YO BLOCK MAP RIG.WAv nC (CIRCLE) STATE MAJOR SECOND LOCAL NO OF 13' (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 (S 100) or less) I USE OF SIZE OF LOT EXISTING BLDG I certify that in the oer ornance A he «ori. `or which his permit is issued I shall not employ ani person n any manner X OWNER _ so as to become subject to the Workers Compensation Lavtisg �� E� OCCUPANCY GROUP MAIL ^ I ADDRESS rL/ Date Avolicant g _ NOTICE TO APPLIC%NT If atter making his CLrtiflcate of CITY .7,L- NO _71,?7i OCCUPANT LOAD - Exemption sou hould become subject o the Workers APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code you must forth �oZ ( 11Ith I,omply WI111 NLL 1 pIokisions oI this -iermit ,hall be TRAILER JSE 71 GEOLOGY INSPEC-ION No Spec Know] deemed resoked _ LICLVSED CONTRACTORS DECLARarION OCCJPAYC Panic Devices NSPEC-ION [8 I hereby affirm that I -m licensed under provisionsot Cllaoter SAFETY PERMIT ❑ (usr ITEMS BELOW) ` 9 (commencing with Section 7000) of Dnision J of the Busi No of EXITS ness and Professions Code and my license is m tull torte and y effect y:ARKIN. REO D PROVIDED n PACES License Number Llc Class LIMITED TIME USE ContraLtor Date DATE DATE L F 40M -O 4 I am exempt Irom hL 1ILensing eouirements _s I -in a I 11Lensed archlteL or a e2istered nrotessional -nern,e IZE D- NO OF INSPECTOR s z acting m mr orotessional LandL t SeL ion -0 1 Bus CY1S NG BLDG STORIES SIG ATURE mess and Protessions Code) PRESENT USE OF BUILDING FINAL APPROVAL LiL or Ree No DdtL (G HOME 0«NER BLILDER DLCLAR%TION No OF EXISTING BUILDINGS ON LOT AND JSE I herebl aftum *hat i Im exempt trom the Contractor s L1Lense Law for the rotlo%lin- reason (Se(, Ion 70.)1 _ Busi ness and Professions Code) NO PARKING t as owner of he nrnpern rill do the cork ma he SPACES PROVIDED structure is -lot intended or otfe Ld for ale (Se(. ion 7044 BUS1rless Ind PIOlessions Code) CO\'STdICIION LLNDI\G aGL\C1 PROPOSED JSE OF BUILDING � 1 11Lrebs affirm that here is a Construction lending dgenLs �aGo _ � Pff1 IQ's'p'- for the performance of the work for Wh1L11 this permit is issued (Sec 3097 Civ C i Lender s Name PROPOSED MAX OCC Lender s Address r,.00 I Lertifv that I hale read this application and state shat the PERMIT FEE abose information is Lorrect I agree to Lompl} %s ith all Colton ISSUANCE FEE ordinances and State la%%s relating to building construction and hereby authoriz representatives of this Countv to enter TOTAL FEE 25.00 upon th ove me oned pro ert} for mspeLtion urp ses SEE RE%ERSE FOR E\PLANATORY LANGUAGE X SIL'I-M n{ n., .+1 r Le D u