HomeMy Public PortalAbout5848ALESSANDRO AVE_Miscellaneous (2) WORKERS COMPENSATION DECLARATION 76M444 y
CE 875 (280) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure"or a certificate of Workers Compensation Insurance or
a ce tified copy thereof(Sec 3800 Lab C) y v
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADD RES U
❑ Certified copy Is hereby furnished BUILDING LOCALITY
ADDRESS
❑ Certified copy is filed with the county building inspection NEAREST
department LOCALITY CROSS ST t
Date Applicant NEAREST C DISTRICT NO GROUP TYPE PR ESSED BY
CROSS ST �� CONSV
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL l/
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SECOND LOCAL d
(This section need not be completed if the work involved NO OF BLDGS USE ZONE SPECIAL CONDITIONS O
P TRACT NOW ON LOT
by the permit is for one hundred dollars ($100) or less)
USE
SIZE OF LOT EXISTING
V
NG BLDG cc
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 t ��(�� �� U
so as to become subject to the Workers Compensation Laws MAIL l / OCCUPANCY GROUPWZI W
ADDRESS.. S v� �� d
Date Applicant rn
NOTICE TO APPLICANT If after making this Certificate of CITY �QCt� NOL Pj ( OCCUPANT LOAD
Exemption- you should become subject to the Workers
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
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) - 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 ��� ` )
effect PARKING
v
SPACES REO D E- PROVIDED
License Number Lic Class
1 LIMITED TIME USE _
Contractor Date DATE e _ o jq=EEE
❑ I am exempt from the licensing equirements as I am a. FROM TO
licensed architect or a registered professional englreer SIZE OF O OF _ INSPECTOR S
N
acting In my professional capacity (Section 7051 Bus EXISTING BLDG STORIES _-SrGNATUQF, _
mess and Professions Code) PRESENT USE OF BUILDING Llv` FINAL APPROVAL
Lic or Reg No Date T V- 1
HOME OWNER BUILDER DECLARATION NO of EXISTING BUILDINGS p
ON LOT AND USE t`l/
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) SP PARKING i V
SPACES PROVIDED
❑ I 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)
PROPOSED USE OF BUILDING _
CONSTRUCTION LENDING AGENCY / Q F
I hereby affirm that there is a construction lending agency ) x 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
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 TOTAL FEE
and hereby authorize representatives of this County to enter
up a above ment ;roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Date