HomeMy Public PortalAbout4824 CLOVERLY AVE_Miscellaneous__ ` W
ORKERS'COMPENSATION DECLARATION CE 84 54( 1 84) M I SSC E L LA N E O U S APPLICATION
I hereby a cert that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, c/ a certificate of Workers'Compensation Insurance,
e,or
a-certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING j q �j s
ADDRESS '( C Ov� /
Certified copy is hereby furnished. Bu1LDING 2
ADDRESS • L LOCALITY ��c C�
Certified copy is filed with the county building inspection LOCALITY l�
NEAREST
department. •�t -mQ(_eC,1 cRoss ST.
Date Applicant NEARESTn ^ DISTRICT NO. GROUP TYPE P CESSED BY
I
CROSS ST. _®U0 ` _ C7CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP MIGRWAY
' NO. (CIRCLE) STATE MAJOR SECOND LOCAL
1N0. 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 �./
SIZE OF LOT t�� Sv EXISTING BLDG. / �,� / d
I certify that in the performance of the work f r whit this VVV
0
permit is issued, I shall not employ any perso any ma ner OWNER f�(,.- �j l_ —50AJ 1�al so as to bec�lome subject to the W s' Co pensatio awAIL OCCUPANCY GROUP o
i /y + ! ADDRESS
Dated ApplicanL. LU
NOTICE TO APPLICANT: If, after 'tate o CITY NO. OCCUPANT LOAD N
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 oI this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Know[. El
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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. 0&6 PARKING
/'� � SPACES REq•D � PROVIDED
License Number Oyu Lic. Class
� �� acK �zy--9i LIMITED TIME USE
Co ntracto ate DATE DATE
I am exempt from the licensing requirements as I am a ' FROM: TO: 4
licensed architect or a registered professional engineer SIZE ofO --/ No. OF . INS `ECTR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. ( STORIES I .7E
NA/URE
iness and Professions Code). FINAL APPROVAL /
PRESENT USE OF BUILDING i f
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDING ij
ON LOT AND USE '••'-
I hereby affirm that I am exempt from the Contractor's ?�•4.
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING
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). _(T j n,0
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm that there is a construction lending agency „_E
for the performance of the work for which this permit is li!rta
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. .il 0 ii
Lender's Address _ ”'' - - -
PERMIT FEE '?•j;;
I certify that I have read this application and state that the f L 4 Arl1 '
above information is correct.I agree to comply with all County ISSUANCE FEE —
ordinances and State aws lating to building construction,
and hereby autho ' e repre ntatives of this County to enter TOTAL FEE
upon the above- entio p perty for' spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S n of Permi e Date