HomeMy Public PortalAbout5848ALESSANDRO AVE_Miscellaneous (3) WORKERS'COMPENSATION DECLARATION
CE 875(11-84)
I CE 875 M I SC E L LA N EO U S APPLICATION
I here23y 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 certified copy thereof(Sec. 3800,Lab.C.). f
Policy No. Company FOR APPLICANT TO FILL IN BUILDINADDRESS 0"7G p�/f ��
FICertified copy is hereby furnished. BUILDING ��i�f/ p LV$ � *� pg
ADDRESS DR ESS Y'D /T !� t71" LOCALITY
E Certified copy is filed with the county building inspection LOCALITY
/�/ /y NEAREST
department. CROSS ST.
Date Applicant x NEAREST C / DISTRICT NO. G OUP TYPE PR CESSED BY
CROSS ST. �./ U •'✓ �/ CONST. �
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q �/
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 perwS
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. ro
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPW211
o
Date Applicant ADDRESS / (�
NOTICE TO APPLICANT: If, after making this Certificate of CITY , �C'� No� / r OCCUPANT LOAD z
Exemption,' you should become subject to the Workers' APP KATION 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 ❑ 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 Busi SAFETY PERMIT (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code,.and my license is in full force an`
� �„nom,
effect. II//�� X/��" PARKING
SPACES REQ'D D PROVIDED D
License Number Lie. Class �/``L
LIMITED TIME USE
Contractor Date DATE DATE
SIG URE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF / —, NO. OF INSPEC oR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code). s O FINAL APPROVAL j r
'\ PRESENT USE OF BUILDING b l
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's D
License Law for the following reason (Section 7031.5, Busi- �. ;'I`I';, _
ness and Professions Code): NO. PARKING _.
0 I, as owner of the property, will do the work and the saaces PROVIDED ✓� _ L a Ii '
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPosED USE of BUILDING < S
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 r
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 f this County to enter TOTAL FEE +
upon above mentioned pi pection pu poses.
� /• SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee G ate