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Home My Public Portal About4921 CLOVERLY AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 M I$,C E LLA N E O U S APPLICATION I hereby affirm that I have a certificate of consent to self CE 875 (11 84)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) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certil'ned copy is hereby furnished ADDRESS DDRE55 Cj LOCALITY department copy is filed with the county building inspection LOCALITYIF NEAREST c C_ p CROSS ST Date Applicant NEAREST DISTRICT NOG!!lUP TYPE P ESSED BY CROSS ST D� .�J/ CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'rTl COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHW wY NO OF BLDGS NCIRCLE) STATE MAJOR SECOND LOCAL O /� ( (This section need not be completed of the work involved TRACT NOW ON LOT USE ZONE SPE IAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF SIZE OF LOT EXISTING BLDG 16b .</ d I certify that in the performance of the work for which this C:) permit is issued, I shall not employ any person in any manner OWNER. OZ4LJAy so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP K o ADDRESSAW k� ] F.- Date Date Applicant 66 L„ NOTICE TO APPLICANT If, after making this Certificate of CITY NOLpJ� 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 or this permit shall be deemed revoked TRAILER USE E:] GEOLOGY INSPECTION E] No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter - 9 (commencing with Section 7000) of Division 3 of the Busr SAFETY PERMIT ❑ LIST ITEMS BELOW NO OF EXITS ness and Professions Code,and my license is in full force and effect ,I PARKING REQ D D PROVIDED D SPACES License Number Lnc Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the Incensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF PROM TO INSPE OR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIG E R mess and Professions Code) FINAL APPROVAL Llc or Reg No Date PRESENT USE OF BUILDING "moo L HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS / =� ON LOT AND USE T.g I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness usr ��Q� ii��}� El1, and Professions Code) NO PARKING *3 I, as owner of the property, will do the work and the SPACES PROVIDED 1 ITEMS structure is not intended or offered for sale (Section 7044,Business and Professions Code) TOTAL 219 - 75 CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING S CHEC , `19.7 I hereby affirm that there is a construction lending agency ��A��E �� 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 i./�.15lV- 1 08/26/9 , �M r��'� 6 I certify that I have read this application and state that the AM1 PERMIT FEE 5715 1 0:4 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 �� J upon above mentioned pro rty for nnspectn purp ses SEE REVERSE FOR EXPLANATORY LANGUAGE ngnature ermnttee Date