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Home My Public Portal About5846ALESSANDRO AVE_Miscellaneous (6) I WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION , I hereby affirm that I have 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 FOR APPLICANT TO FILL IN BUILDING ❑ -nd ADDRESS �4 Certified copy Is hereby furnished BUILDING LOCALITY ess Tleemple Certified copy Is flADDRESS 5846 Aled with the county building inspection LOCALITY Tem le CV3.tCA NEAREST department c P ,/ CROSS ST Date Applicant NEAREST � / � DISTRICT GR TYPE aRE;; BY ED CROSS ST Las Tunas �{'� CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL ✓ DESCRIPTION LOT NO BLOCK COMPENSATION INSURANCE MAP (CR LE) STATE MAJOR SECOND LOCAL } NO OF BLOGS r+o IRCd (This section need not be completed if the work involved TRACT w NOW ON LOT USE ZONE S ECIAL CONDITIONS 0 by the'permit is for one hunI dred SIZE dollars ($100) or less) _ OF LOT EXISTING BLDG USE OF U I certify that in the performance of the work for which this 0 permit is Issued I shall not employ any person in any manner O N Joyce Chen U so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP LV Date Ll ADDRESS' 60J�4 S Old Ranch Rd a Applicant N I TEL NOTICE TO APPLICANT If after making this Certificate of-to cirY Arcadia` CA rvo'I = OCCUPANT LOAD Z 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 Or this permit shall be TRAILER USE GEOLOGY INSPECTIONNOS Spec Knowl Eldeemed revoked P ❑ OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION I hr.reby affirm that Tam Licensed under provisions of Chapter SAFETY PERMIT'Q (LIST ITEMS BELOW) ^q 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 PARKING efrjeCt SPACES REQ D O PROVIDED O License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ❑ Y I am exempt from the licensing TO requirements as I am a , licensed architect or a registered professional engineer r SIZE OF NO OF INSPECTOR S acting in my professional capacity (Section 7051 BUS EXISTING BLDG STORIES SIGNATURE iness and Professions Code) ESENT USE OF BUILDING Office FINAL APPROVAL Lic or Reg No Date 71/ZZ HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS # 0 0 0 0 8 8 ON LOT AND USE O O O O O O O Z I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busl 12,09-83 ness and Professions Code) NO PARKING SPPCES PROVIDED Eli as owner of the property will do the work and the structure is not Intended or offered for sale (Section 7044 Business and Professions Code) OPOSED USE OF BUILDING Same CONSTRUCTION LENDING AGENCY 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 PERMIT FEE I certify that I have read this application and state that the 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 inspec n purposes SEE REVERSE FOR EXPLANATORi�GUlIAAGEGE 12/5/83 Signature of P Ittee ' Date i r