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Home My Public Portal About5508 CLOVERLY AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8454(1 1 64) MISCELLANEOUS APPLICATION I Jiereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Vsure, 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 ` t ADDRESS / J Certified copy is hereby furnished pDJLD DRES^yJ $ /)I J,/ab�2L fiU6 ' LOCALITY Certified copy is filed with the county building inspection LOCALITY l G ryl S1 C` / t NEAREST department' 1 (. "17 ( CROSS Sr Q` Date Applicant NEAREST DISTRICT NO G OUP TYPE PRO SO BY CROSS ST 2CJ/�L�u/�' S CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a J COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO 6 (CIRCLE) STATE MAJOR SECOND LOCAL NO OF BLD63 ' (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 ($100) or less) SIZE OF LOT /- .f u9 DF /OO X(pJ EXISTINGsBLDG ,eS/� J \�' I certify that in the performance of the work for which this, C!) permit is issued, I shall not employ any person in any manner OWNER re Al Fl,o(&k. _ +, `l' so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP F\7f �j� MAIL `� pDate o � Applicant l- / �Y //�• ADDRESSSj OS KO �kOU&fLL �{J E� _x v ��,,`t ti, � NOTICE TO APPLICANT If, after making this Certificate of CITY ��f NO ��( — a s S r OCCUPANT LOAD I LUTELZ Exemption, you should become subject+to the Workers' APPLIC TION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec Knowl deemed revoked C 1' LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO OF EXITS nessnd Professions Code, and my license is in'full force and C/l(C�o$G �i(; /g effectI PARKING REQ D PROVIDED D SPACES License Number Lie Class LIMITED TIME USE Contractor DateD ATE DATE 0 1 am exempt from the licensing requirements as I am a ` 4- C_ 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 r SIG ATURE mess and Professions Code) PRESENT USE OF BUILDING Rt—,�,fp6wCC FINAL APPROVAL / Lie or Reg No Date HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS 611630 ON LOT AND USE I hereby affirm that I am exempt from the Contractor's - A(( a .r License Law for the following reason (Section 7031 5, Busi- nes and Professions Code) NO PARKING ?� `, 3307 C"', 30.58 SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ? ITEM'�\ 7044,Business and Professions Code) `` TOTAL ��,P0- 0 PROPOSED USE OF BUILDING L t ,� _ ' -CHECK ,' � +°al•�1 I hereby affirm that there is a construction lending agency eIN CHANGE, for the performance of the work for which this permit is 1 issued(Sec 3097,Civ C) Lender's Name - PROPOSED MAX OCC 13000-0001 Lender's Address l�1 PERMIT FEE I certify that I have read this application and state that the �1Q7 1 1,13.,52 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 upon t1w above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date