HomeMy Public PortalAbout5846ALESSANDRO AVE_Miscellaneous (3) WORKERS'COMPENSATION DECLARATION 76M444 - MISCELLANEOUS A P P L I C A T I O N
I hereby affirm that I have a certificate of consent to self CE 875(11-84)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
Certified copy is hereby furnished. BUILDING LOCALITY l i^
XX ADDRESS '�ffl& Itis 47 _
Certified copy is filed with the county building inspectionLOCALIT CRAREST
OSS ST.
NE
department.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE OCE SSED BY
CROSS ST. CONST:
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND 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. C
I certify that in the performance of the work for which this c
permit is issued, 1 shall not employ any person in any manne3CX OWNER of building
so as to become subject to the Workers' Compensation Laws. uJ c
MAIL _I OCCUPANCY GROUP C
ADDRESS � G G
Date Applicant G
EL' OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of I CITY d t Cq qlp NO-TTIL _ 7,01
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 GEOLOGY 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
9 (commencing with Section 7000) of Division 3 of the BUST SAFETY PERMIT LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code,and my license is in full force an*X I�
effect. Name of business PARKING REQ'D PROVIDED IBJ
SPACES II��
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
F,IOM:
I am exempt from the licensing requirements as I am a TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. O� Q r STORIES /
SIG TURF-
inessandProfessionsCode). FINAL APPROVAL
11-10+(
PRESENT USE OF BUILDING ��ot+
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Q e ON LOT LOT AND USE
I hereby affirm that I am exempt from the Contractor's V
License Law for the following reason (Section 7031.5, Busi /b ' G r/D�1 G I,;1;;;''-••I
ness and Professions Code): NO. PARKING _
1, as owner of the property, will do the work and the spaces PROVIDED ' g- t�Be E _ _ F l
structure is not intended or offered for sale (Section [PROPOSED
7044,Business and Professions Code).
USE OF BUILDING:CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency �iE'/giL�S
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). GfO S 4� a iT
Lender's Name lyr
PROPOSED MAX. OCC.
Lender's Address
I certify that 1 have read this application and state that the PERMIT FEE
25 - 00
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
:Ind hereby authorize representatives of this County to enter TOTAL FEE 25 - 00
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
XX XX
Signature of Permittee Date