HomeMy Public PortalAbout5846ALESSANDRO AVE_Miscellaneous (2) i WORKERS' COMPENSATION DECLARATION' 7FM444
c= 13�s �t 1-aal MISCELLANEOUS APPLICATION
-
1 hereby affirm that I have a certificate of consent u> r COUNTY OF LOS .ANGELES [BUILDING .AND SAFETY DIVISION �
insure. or a certificate of 11`orkers'Cinnpensation Insurance'or'
r� a certified copy thereof(Sec. 3800. Lab.C.1.
�I Polici.• No. _Company — FOR APPLICANT TO FILL IN BUILDING
ADDRESS
El -7
Certified copy is hereby furnished. BUILDING 5P,// A1!'ss ,I ft"f/•e�
R ADDRESS '4 apdeQ LOCALITY A
1 Certified cop\' Is tiled«ith the count building inspection LOCALITYNEAREST
department. Temple City CROSS ST.
Date Avrilicant NEAREST ]� 715 TR ICT NO. GRO P TYPE OCESSED BY
CROSS ST. LQ'S �UYIRS DY' /�D// CONY
I CERTIFICATE OF EXEMPTION FROM '.10RKERS LEGAL s OY J
COMPENSATION INSI RANC E OESCA IP T: I. LOT NO. '.BLOCK I MAv GHw qv
STATE MAJOR SECOND LOCAL
I NO. OF BLDGS.
(This section need not be completed If the work involved �TRaC- ^lOIY ON LOT^IOIY ON LOT USE ?ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (51001 or less.) ��
USE TI t
1 ' SITE OF LOT �EXISTING BLDG.
I eertifv that in the t e-fornance rf he '. ,?rl: 'or .vhich :his
permit is issued. 1 ilial not employ" any ne-sott :n any manner OWNER Wien T �
T. e
so as to become suhiect to the llorkers' C.,ntnensatiI, !.ADTe, MAIL I_ ��',//✓!,'�r j OCCUPANC':' 3ROUP _
MAIL
ESS k)4 Sd. (Did RaKc l l�
1 Date Applicant _ _—
NOTICE TO APPLICANT: If, :u,er makin_• :!:is CeTr irate �\f XI CIT Y uc��u'� '��gZ OCCUPAN- LOAC
Exemptio�i. trou <liould become iubiect :o -he 11'x.-ke-s
Compensauon prmisions of the Labor % ode. You must to_Th-
I with comoiy with <uch nro\'is:ons o- his emir iltail be -RAILER :15E GEOLOGY 'NAPE':=T:CY _ No S oP.C, K:1C':'l1,
deemed -e\oi:ed.
LICENSED CONTR.ACTORS DECL.-xR.ATIOI:
OCCUPANCY INSPECTION Panic Dev;ces ❑
hereby affirm that l am licensed under previsions of Chat ter a
i SAFETY PERMIT u (LIST ITEMS 3EL0.'/)
C
9 (commencing with .Section 000) of Division 3 .\t the Bus'' / NO. OF EXITS
ness and P-ofessions Code. and my licenm is in 'u!1 fore: and
et!eL•t, PARKINGj
N /
SPACES
REO'° I I PRO'✓ID EO
License Number I_ic. C!asi
-- LIMITED TIME USE
Contractor-_-__ _- Date DATE °A-E
W
Z oDM: TO:
I am exempt from the licensing require;tents as I am a
M I licensed archirect or a registered nrnfesMonal engineer SIZE OFNo-TO.POS
S TF INs cTOR s
\ �� ��� -I\. I. ORE
z acting in my proles ional r:r;r' 1:1_ ;1. Btli-
EXISTING BLDG.
inesi and Psofessicns Cadel. — -----T
FINAL APPROVAL
U ''RESENT USE OF BUILDING
Lic.or Re_ No. -
HOME O11N1 R-BUILDER DECL.ARAFION NO. OF EXISTING BUILDINGS
ON LOT AND USE
! hereby affirm that I am exempt From the Contracts j s E0130- ?i i
( License Law for the following reason 'Section -031.3. Bu.si
n - ,_
ness and Professions Code): NO. PARKING U' �I;'+;_; i
SPACES PROVIDED
1, as owner of the proper[}'. will du the work and the
structure is not intended or offered for :ale (Sect;on
1 7044. Boeings and Professions Code).
CONSTRUCTION LENDING .AGENCY X PROPOSED USE OF BUILDING V� f tCe DLI T¢� al ke
I hereby affirm that there is a construction lending agency �t�y�eSa�tVQe�t-� Du� (3V
I for the performance of the '.vork for which this permit is Oy �Yl
issued'Sec. 3097•Civ. C.). 1e -
---,c LA '
Lender's Name
PROPOSED MAX. OCC.
Lender's address
PERMIT FEE 25.00
I certify that I have read this application and ,tate that the.
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building constructi:Jn,
and herebv authorize representatives of this County to enter TOTAL FEE 25.00
I upon the ove-mentioned Toperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
I .