HomeMy Public PortalAbout5737ALESSANDRO AVE_Miscellaneous :OMPENSATION DECLARATION CE 8.75 54(1 1-84) MISCELLANEOUS APPLICATION
at I have a certificate of consent nc self
a �te of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
ed copy tnereof(Sec. 3800;Lab.C.).
Vo. Company, FOR APPLICANT TO FILLIN
BUILDING
ADDRESS a
J
Certified copy is hereby fUInlShed' AD RES9 �
�}� . � TY
� LOCALI / r
Certified copy is filed with the county building inspection LOCALITY ]� NEAREST
s
department. ` f % CRosS ST.
Date Applicant NEAREST DISTRICT NO. OUP TYPE R •C ESSED BY
CROSS ST. I •A/ �-y� 4 _3CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LE:GALG�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND 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 hundred dollars ($100) or less.) / // use
SIZE OF LO
T�� / EXISTIN
I certify that in the performance of the work for which this
permit is issued, l shall not employ any person in any manner OWNER
so as to become subject to'the Workers' Compensation Laws. ° OCCUPANCY GROUP
MAIL
Date Applicant ADDRESS �AAJ� } ,
TEL � G y�i 1 OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY. G L.� ✓/ NO.
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such..provisions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. .
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
El
I hereby affirm that I am licensed under provisions of Cliapter 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 +� _ //_ g�/
effect. ,/'�• fC/ IE yY ' PARKING
_ �- SPACES REq•D � PROVIDED
License Number Lic. Class — y/ A y�1 `�'' LIMITED TIME USE -
Contractor Date s-t/✓✓✓fff"" ` DATE DATE
p � �L 1x� / FROM: TO:
I am exempt from the licensingrequirements as I am a /
licensed architect or a registered professional engineer SIZE OF +*' NO. OF INSPECTOR'S
acting m .Illy professional capacity (Section 7051, BUS- EXISTING BLDG. � -!w
d E STORIES SIG TURE
inessandProfessions Code). 1 1�,.+ —FINAL APPROVAL
PRESENT USE OF BUILDING fCG ( /
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE •� �"•' t:
I hereby affirm that I am exempt from the Contractor's JL
`y '
License Law for the following reason (Section 7031.5, Busi- / 7 ,� ,epi • �;'� �Ca H '_Lar
ness and Professions Code): NO. PARKING -7
I, as owner of the property, will do the work and the SPACES PROVIDED -••- •v:-•
structure is not intended or offered for sale (Section . . .
7044,Business and,Professions Code).
CONSTRUCTION LENDING AGENCY - PROPOSED use of BUILDING _
CHD"'•.
I hereby affirm 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
PROPOSED MAX. OCC. �1 .�i t—IES it,-ry :rl �):` •`
Lender's Address '^
PERMIT FEE 2_02- 0S I `"•_. j?a t
I certify that I have read this application and state that the -� - Ns:a.t•5
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
upm le abo -mentioned prope y for inspection purposes.
fl,� > SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date