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HomeMy Public PortalAbout5848ALESSANDRO AVE_Miscellaneous WORKERS COMPENSATION DECLARATION CE 875(11 84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm 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 FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnishedBUILDING �i .cc—.�fir © O ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant NEAREST �L7 DISTRICT NO GROUP TYPE PR CESSED BY CROSS ST Yr _� CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION 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 /y n SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this O permit is issued I shall not employ any person in any manner OWNER so as to Vbeublect to the Wor�k/ers Comppenns�ation Laws MAIL OCCUPANCY GROUP aoDate/ A licant �A4pwAVU/� � ADDRE35 PP 5 —r—bi ?/�7TEL/�lnr _ " OCCUPANT LOAD NOTI LICANT If after making this Certificate of CITY �¢- 7 No ` i ! n 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 INSPECTION El deemed revoked ❑ ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El 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 C //�� c//•y' �` effect O J J/,• �7� PARKING �,p SPACES REpD PROVIDED License Numbe Lic Class!f��E ��''� LIMITED TIME USE Contractor Date DATE DATE 0 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 ATURE mess and Professions Code) FINAL APPROVAL Lic or Reg No Date PRESENT USE OF BUILDING 4_C/Z- two owo-wo l l/ 4/4, HOME OWNER BUILDER DECLARATION NO OF EXISTING UILDINGS ©� G� /41f} 1 [[�I 4�� ON LOT AND USE I -J ] I hereby affirm that I am exempt from the Contractors " " License Law for the following reason (Section 7031 5 Busr 0 ness and Professions Code) NO PARKING DI 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 I hereby affirm that there is a construction lending agency G 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 o{SQ above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction n��O and hereby thorize r presentatives of this County to enter TOTAL FEE R_ upon the nt n pef y for inspection p pos r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of �rmrttee ate