HomeMy Public PortalAbout5622 CLOVERLY AVE_Miscellaneous__ • , Wn,RKERS'COMPENSATION DECLARATION CE 875(2 80) 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 certified copy thereof(Sec 3800,Lab C) t
PolicyNo Com any BUILDING
P FOR TO IN - AODREss
❑ Certified copy Is hereby furnished L,1 BUILDING LOCALITY
ADDRESS
FCertified copy is filed with the county building Inspection NEAREST
department LOCALITY /J /� cRoss sT
C- c' W n
Ddte Applicant - 'NEAREST IDISTRICT NO GR UP TYPE PROC ED BY e
CROSS ST YI 5 /i CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SEC D LOCAL d
NO OF BLDGS 0
(This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less) USE OF
r
SIZp OF LOT EXISTING BLDG Ir
I certify that-in the performance of the work for which this 0
permit Is Issued, I shall not employ any person in any manner OWNER ,U
so as to become-subject to the Workers' Compensation Laws Vf'A e OCCUPANCY GROUP — UJ' ADDRESS r W
F
Date Applicant -
NOTICE TO APPLICANT if, after making this Certificate of CIT e�j NOL — OCCUPANT LOAD z
Exemption, .you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION
E)
deemed revoked ❑ No Spec Knowl
- Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bust
ness and Professions Code, and my license is in full force and PARKING
effect SPACES REQ D D PROVIDED
License Number Lie Class
- LIMITED TIME USE
Contractor Date DATE DATE
RROM TO
ElI am exempt from the licensing requirements as I am a _
Ilcensed architect or a registered professional engineer SIZE OF NO OF INSP CTOR s
acting in my professional capacity (Section'7051, Bus- EXISTING BLDG STORIES S NATURE
mess and Professions Code) FINAL APPROVAL
ESENT USE OF BUILDING ,_9O+ -
Lie or Reg No Date ((��
HOME OWNER BUILDER DECLARATION NO ON LO
EXISTING BUILDIN s
OT AND USE , 2321. 1 A
I
I hereby affirm.that I am exempt from the Contractor's � � + �
License Law for the following reason (Section 7031 5, Bust '
# 00 • • 88
ness and Professions Code) NO PARKING
SPACES PROVIDED 0 0 0 0 0 0 0
I, as owner of the property, will do the work and the
structure isnot intended or offered for sale (Section
7044, Business and Professions Code) t
P POSED USE OF BUILDING - ' I (�lR 87'85
1
CONSTRUCTION LENDING AGENCY
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
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 reby authorize representatives of this ounty to enter TOTAL FEE_
Lupo t a ove rpentiorye� operty f ms ection to
SEE REVERSE FOR EXPLANATORY LANGUAGE
�/
SlgnIture of Permittee Date