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Home My Public Portal About5842ALESSANDRO AVE_Miscellaneous WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have 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 BUILDING Company FOR APPLICANT TO FILL IN ADDRESS , ❑ Certified copy is hereby furnished BUILDING LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection C department LOCALITY _ ` 1---SS ST Date Applicant AREST DISTRICT NO GROUP TYPE PROCESSED BY CROSS ST CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO NO (CIRCLE) (This section need not be completed if the work involved TRACT NO WOONBLOT S USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less) USE OF l V SIZE OF LOT EXISTING BLDG f ( 1= I certify that in the performance of the work for which this 0 permit Is issued I shall not employ any person in any manner wNER so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP �J _ 0 ADDRESS 's`� W Date Applicant NOTICE TO APPLICANT If after making this Certificate of cl> NOL OCCUPANT LOAD Exemption 1 you should become subject to the Workers -fLA�A4PPLICATI yN 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 Cl No Spec Know[ ❑ deemed revoked Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I iereby affirm that I am IlLensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busl ss and Professions Code and my license Is in full force and PARKING e ect SPACES REQ D O I PROVIDED License Number Llc Class LIMITED TIME USE Contractor Date DATE DATE ❑ f a FROM TO I am exempt from the licensing requirements as 1 am 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 mess and Professions Code) • FINAL APPROVAL � ESENT USE OF BUILDING Lic or Reg No Date C r HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE �24634A I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi # 0 0 0 0 8 8 ness and Professions Code) NO PARKING SPACES PROVIDED ❑ I as owner of the property will do the work and the s,o 0 0 0 0 o z J I I i structure is not intended or offered for sale (Section 7044 Business and Professions Code) o8. 19-83 P POSED USE OF BUILDING CONSTRUCTION LENDING AGENCY ; t 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 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 TOTAL FEE and hereby a horize representatives of this County to enter UPV,kthe dbo a entiproperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE - C-.:l �- ,.� �%`"' eg Signature of Permittee Date