HomeMy Public PortalAbout5701 CLOVERLY AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N /--I
CE 875 (11-84) r
I hereby affirm that I have a certificate of consent to self' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, o4certifipate of Workers'Compensation Insurance,or
a certifiecopy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Q r1
ADDRESS l/
Certified copy is hereby furnished. BUILDING Dv Y/�. . V� LOCALITY
ADDRESS ..` I
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST. �1 L/ ®�/`'1\ �`3'✓
Date Applicant NEAREST J DISTRICT NO. G OUP TYPE P CESSED BY
CROSS ST. I Ve_ K CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL '''f 3
COMPENSATION INSURANCE DESCRIPTION LOT NO. [' O BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT I NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) XISTING usE
SIZE OF LOT �, of BLD G.5-10 Ir
X V Ed
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER ��� e,Qr y
so as to become subject to the Workers' Compensation Laws. v P OCCUPANCY GROUP EkE
�
ADDRESS
Date Applicant MAIL 0 Ul1e.r `3
® W
NOTICE TO APPLICANT: If, after making this Certificate of CITY ` No� 1��� ��9 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: —
Compehsation 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.
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
ness and Professions Code, and my license is in full force and
effect. Sjbra- v,- SPACESG R..,. PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
a I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF / / NO. OF INSP SIGEN TORE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. Z x a� STORIES / SIGNATURE
iness and Professions Code). Y FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
S OYC,5
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDIN ` 1� y .-(a
ON LOT AND USE a lyzrr�c- Q,
I hereby affirm that I am exempt from the Contractor's ISL• a e
License Law for the following reason (Section 7031.5, Busi- a ✓a - -
ness and essionsCode): No. PARKING _=1}L ;'-�'4-
SPACES PROVIDED
as owner of the property, will do the work and the � �. I T EM:�:
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL 234 - 45
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
j� {•HECK% iJ9 a
I hereby affirm that there is a construction lending agency G 6L.Yc, S'T�t !EIANI�E a!!l.'
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 I 11_
PERMIT FEE D 14�L' i AM I„ea '•
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 �, Q
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the,above-mentio d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date