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HomeMy Public PortalAbout5702 CLOVERLY AVE_Miscellaneous__ q WORIICE`ttS'COMPENSATION DECLARATION CE 875(1 1 84) 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 cop(,thereof(Sec 3800,Lab C) Policy No M Company u FOR APPLICANT TO FILL IN BUILDING � V n�'},/ L ADDRESS (� C () El - P C�rtffied copy is hereby furnished BUILDING 70.2 j LOCALITY t�1 , ADDRESS L 0 Certified copy is filed with the county building mspectlon LOCALITY .—G NEAREST department Gr3�J/1 D/ CROSS ST LwF 01W, Date Applicant NEAREST �`,�`(�` 4G DISTRICT G OUP TYPE P O ESSED BY CROSS ST /� _ CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL qy� ` COMPENSATION INSURANCE DESCRIPTION LOT NO i/ BLOCK �� -Al HIGHWAY rI0 (CIRCLE) STATE MAJOR SECNO OF OND LOCA (This Section need not be completed if the work involved TRACT NOW ONBLOT S USE ZONE Spa CIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF I certify that in the performance of the work for which this sIZE of LOT'j6© (�f j p EXISTING BLDG _ o permit is issued, I shall not employ any person in any manner OWNER ,,// ©/lam `• I�"J so/a,ST to become subject to Workers' Compen ion Laws MAIL v0 OCCUPANCY GROUP a jD¢�QA h ADDRESS PP ?oTEL NOTICE TO APPLICANT If, after making this ertificate of cirY G NO ���— � OCCUPANT LOAD 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl 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 P PARKING REQ D PROVIDED 1 SPACES J License Number Lic Class Q LIMITED TIME USE Contractor Date DATE DATE El FROM TO I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES S NATURE mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lic or Reg No Date ,r HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS - 30 ON LOT AND USE _ I hereby affirm that I am exempt from the Contractor's - AULT License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING y 3�■ 1 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) ti T4TAL m � CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING �� CWCK +� ��1 �80.9.0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit isissued :�", `_'`,� ■�l Lender's e 3097,Civ C F ' i , V/rill/89 PROPOSED MAX OCC ` 1 .'6/20/89 L Lender's Address _ j,IJ G17 I certify that I have read this application and state that the PERMIT FEE uQ 407i 1 AM 8:39 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 the abov entioned roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Z`o2D Z69 Signature of P ttee Date