HomeMy Public PortalAbout5846ALESSANDRO AVE_Miscellaneous ( I WORKERS COMPENSATION DECLARATION 200063DPW12/90 MISCELLANEOUS APPLICATION
I hereby 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)
Policy No Company FOR APPLICANT TO FILL IN BUILDING '
BUILDING ADDRESS ,� ADDRESS
HCertified copy is hereby furnished g Lf ,L,ll . o /(vim` LOCALITY
Certified copv is filed with the county building inspection CITY �, n ZIP �(o
t department 7&41, LL ( t 9��v O NEAREST
CROSS 5T
Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP I TYPEPROCESSED BY
CL
CERTIFICATE OF EXEMPTION FROM WORKERS O CONST
( I COMPENSATION INSURANCE TRACT BLOCK LOT NO MAP HIGHWAY O
No taacLel STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL uSE ZONE SPECIAL CONDITIONS to
by the permit is for one hundred dollars ($100) or less) Q
U
r i� p
s i I certify that in the performance of the work for which this � er EL NO
�I rfy �k�
permit is Issued I shall not employ an} person In any manner Z� �� W
so as to become subject to the Workers Compensation Laws ADDR[ S t7OCCUPANCYz GROUP �
{ I Date Applicant CITY �E ZIP✓✓ .0 y-0 7
NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD
of Exemption_you should become_sub}ect to_the Workers_ __ -APPLICATION FOR - - J
Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE
( comply With such provisions or this peimit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑
revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Ch ipter SAFETY PERMIT❑ (LIST ITEMS BELOW) --Ell
i 9(commencing with Section 7000)of Division 3 of the Business NO OF EXITS
and Professions Code and my license is in full torce and effect ame O us IIOss
PARKING REO D D PROVIDED D
I License Number Lic Class 1 C S�2C ��C iSPACES
+ i I Contractor Date / LIMITED TIME USE
I ❑ I am exempt from the licensing requirements as I am aIFROMF TO
DATE DATE
licensed architect or a registered professional engineer
t acting in my professional capacity (Section 7051 Business SIZE EXISTING BLDG NO OF
RIES INSPECTO RE
and Professions Code)
Lic or Reg No Date PRESENT USE OF BUILDING FINAL APPROVAL
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 70315 Business 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 7044 X PROPOSED USE OF BUILDING
Business and Professions Code)
CONSTRUCTION LENDING AGENCY C
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
( ( PROPOSED MAX OCC
Sec 3097 Civ C)
Lender s Name APPLICANT(PRINT) T L NO
J
Lender s Address ADDRESS
{ I certify that I have read this application and state that the
above information is correct I agree to comply with all County PERMIT FEE
I ordinances and State laws relating to building construction and
hereby a home representatives of this County to enter upon ISSUANCE FEE
the a - entioned property for inspection purposes
I 1 TOTAL FEE
% SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
x