HomeMy Public PortalAbout6121 AVON AVE_Miscellaneous__ WORKERS;COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm 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.).
LL IN BUILDING
FOR APP LI CANT TO FI
Policy No. Company ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST /^� +J DISTRICT NO. GROUP TYPE P CE SSED BY
CROSS ST. 11 i4/ 4 L- Q v E �D L Q CONST.` /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL n o /` V rji!
COMPENSATION INSURANCE DESCRIPTION LOT NO.,V BLOCK MAP HIGHWAY
NO. (CIRCLE)
STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT ^ lA Q NOW ON LOT USE ZONE SPECIAL CONDITIONS
by .the permit is for one hundred dollars ($100) or less.) SIZE OF LOT ss I USE EXISTING BLDG.OF
I certify that in the performance of the work for which this CD
permit is issued, I shall not employ any person in any manner OWNER ='
so as to become subject to the Workers' Compensation Laws. 1 S OCCUPANCY GROUP
Date A licant ADDRESS 1 VQ r4 U
N JE �-�
,+� a LIJ
U
NOTICE TO APPLICANT: If, after making this Certificate of clr ( L TE
( ��95 6 7 6 ( OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
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. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ
El
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 r h
effect. vO�7 J PARKING REQ'D PROVIDED
SPACES
License Number Lie. ClassGe�c �
,orLIMITED TIME USE
Contractor Date DATE DATE
El I am exempt from the licensing requirements as I am a
FROM: To.
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
inessand Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date !
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS {i
ON LOT AND USE "
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED �� �-
structure is not intended or offered for sale (Section i l='•F.
7044,Business and Professions Code). 3 ,; aa _:
_ _ a _.
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency "
for the performance of the work for which this permit is ,:-??j[I`_ I
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
��D
I certify that I have read this application and state that the PERMIT FEE ;';7 -, :�41
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 , 76
upon the above-mentioned property for inspection purposes.
t7 J _ / !a` l.Z SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Permittee Date