HomeMy Public PortalAbout5846ALESSANDRO AVE_Miscellaneous (4) WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby a cIT
ert that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company BUILDING
�p
FOR APPLICANT TO FILL IN pDDREsS
Certified copy is hereby furnished. ILO
DRSS,I N G674
�7 0 e LocALITY
ADE
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY
CROSS ST. , OQ _� CONST/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLDGS. NO. (CIRCLE)
(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.
Icertify that in the performance of the work for which this �-
permit is issued, I shall not employ any person in any manner OWNER I a ohem
so as to become subject to the Workers' Compensation Laws.
MAIL OCCUPANCY GROUP J
0
Date Applicant ADDRESS 60 OLI7ch d F--
U
TEL./ ` V"1
NOTICE TO APPLICANT: If, after making this Certificate of CITY NCI (�/� Z OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: _
with comply With such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E]
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING
(V✓ '�iyN ra�merr� C� SPACES REQ'D PROVIDED
License Number Lie. Class LIMITED TIME USE II��
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date
Yetct; ove
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ��� il1J ?
License Law for the following reason (Section 7031.5, Busi- C/ ____
ness and Professions Code): . F40. PARKING ,�. s 17 1 PM ft;'2-*3
❑ I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
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 arize representatives of this County to enter TOTAL FEE
upon the ab e- ent4nouroperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur 'of Pert
er ittee // Date