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HomeMy Public PortalAbout5844ALESSANDRO AVE_Miscellaneous (3) t W(3RKERS'COMPENSATION DECLARATION CE 75 M I.SC E L LA N E O U S APPLICATION -a CE 875 (11-84) I her_,or affirm that I have a 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.). BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS EJCertified copy is hereby furnished. ILDING n, LOCALITY ,"AS q4A L 'P_ o e• 0 Certified copy is filed with the county building inspection LOCALITY �e It NEAREST department. I:!,; T cRoss ST. Date ApplicantAREST DISTRIC G OUP YPE PRO ED BY CROSS ST. `� CONST., CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT N. BLOCK MAPF/,'/1 j�i IGRwA 1 NO. �(f (CIRCLE STATE MAJOR SECO 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 OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this l/ permit is issued, I shall not employ any person in any manner NERC flQ u, C R e "CD � so as to become subject to the Workers' Compensation Laws. L / OCCUPANCY GROUP Date Applicant ADDRESS LB 014 S ® A-Al C_14 .b. W NOTICE TO APPLICANT: If, after making this Certificate of rY Ho� 8 7 7 f L� 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 oI this permit shall be TRAILER USE f_1GEOLOGY INSPECTION E] No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 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 effect. PARKING SPACES READ PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional Capacity (Section 7051, BUS- EXISTING BLDG. STORIES 51 NATURE iness and Professions Code). SENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date G U I L De 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 .122 6 6 4,2 A 0 I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section # 000 . 88 7044,Business and Professions Code). • • o o ® o o a CONSTRUCTION LENDING AGENCY ROP.SED USE OF BUILDING I hereby affirm that there is a construction lending agency A, © D2P, U u2 A-B lIs .0 3.0 9 i.8 7 for the performance of the-work for which this permit is issued(Sec. 3097,Civ.C.). C 1 R Lender's Name PROPOSED MAX. OCC. Lender's Address 5_ Q I certify that I have read this application and state that the PERMIT FEE 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 upon the above-mentioned property for inspection purposes. K,O . ) P /I —9'7SEE REVERSE FOR EXPLANATORY LANGUAGE –�� Signature of Permittee Permittee ,/ Date /