HomeMy Public PortalAbout5844ALESSANDRO AVE_Miscellaneous WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS, APPLICATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
of certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
Certified copy is hereby furnished. BUILDING ,,JJ
// LOCALITY ..
❑ ADDRESS �•`
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY C CROSS ST.
Date Applicant AREST DIS'RtC] NO. I—GFuP TYPE JPROIE ED BY
CROSS ST. 'd ✓ Daayy �7- CONST. _
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 1 ✓ H,GI.IWAY -
rvo. j4-0,0 (CIRCLE) STATE MAJOR SECON LOCAL
NO, OF BLDGS. a,(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITION0S U
by the permit is for one hundred dollars ($100) or less.)
USE TI - Ir
SIZE OF LOT EXISTING BLDG.
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 OWNER U
so as to become subject to the Workers' Compensation Laws. MAL OCCUPANCY GROUP E:V] W
DRESS (� d d
Date Applicant Z
NOTICE TO APPLICANT: If, after making this Certificate of IrY �. NOL 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 USEGEOLOGY INSPECTION '
deemed revoked. ❑ C1 No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION ' Panic Devices '
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and ICIrvG r
effect. PARREq'D o PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor DateDArE DATE
ElFROM: TO:
I am exempt from the licensing requirements as I am a:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S),6NATURE
iness and Professions Code). J;WESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date we"A/11
i
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
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
SPACES PROVIDED
ElI, as owner of the property, will do the work and the 2 4 Q
structure is not intended or offered for sale (Section
7044, Business and Professions Code). POSED USE OF BUILDING # o,e e o $8
CONSTRUCTION LENDING AGENCY • �
I hereby affirm that there is a construction lending agency C 0 0 0 0 • • •'
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). O 7 =8 5
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 ^ 1, `�
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County.to enter
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR,EXPLANATORY LANGUAGE 1
Sig nat r of Per a e \\