HomeMy Public PortalAbout5725 CLOVERLY AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(1 1 84) M I�C E L LA N EO U S APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or++certificate of Workers'Compensation Insurance,or
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a certified copy thereof(Sec 3800,Lab C)
BUILDING
Policy No Company FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished BUILDING , / n L
ADDRESS LOCALITY
F Certified copy is filed with the county building inspection LOCALITY
d NEAREST
department CROSS ST
Date Applicant NEAREST ,/ DISTRICT NO GROUP TYPE PROCESSED BY
CROSS ST /— P — O (f CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C� d
Ve
COMPENSATION INSURANCE DESCRIPTION LOT NO ? BCocK MAP ^ HIGHWAY
NO 2f✓O (CIRCLE) STATE MAJOR SECOND LOCAL
NO OF BLDGS
(This Section need not be completed if the work Involved TRACT 6s- NOW ON LOT USE'ZONE SPECIAL CONDITIONS
by the permit is for one_hundred dollars ($100) or less) ,. - - QO EXISTING BLusE oB�f �W /N
0 C DG a
I certify that m SIZE OF LOT the performance of the work for which this ae. o
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP 3 0
ADDRESS , S
Date Applicant ,,,
NOTICE TO APPLICANT If, after making this Certificate of clrY LQS ^/G�� TNOL OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION
deemed revoked ❑ El No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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 PARKING REQ D D PROVIDED D
SPACES
License Number Lie Class
LIMITED TIME USE
Contractor Date DATE DATE
El I am exempt from the licensing requirements as I am a
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 / SIGNATURE
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING 2.+ 8qs
Lie or Reg No Date
70
f
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE AicCT.Or
I hereby affirm that I am exempt from the Contractor's ���
License Law for the following reason (Section 7031 5, Busi- 30 22 °r'��I
ness and Professions Code) NO PARKINGEl I{ ITEMS
I, as owner of the property, will do the work and the 1
SPACES PROVIDED
structure is not intended or offered for sale (Section TOTS 227 - 70
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 227.71.1,
1 hereby affirm that there is a construction lending agency
lo':+L HANSE
for the performance of the work for which this permit is
issued(Sec 3097,Civ C)
Lender's Name I{0 {x_11 f#7 _
4/� 10 X31 r r-
PROPOSED MAX OCC i ,
Lender's Address !//!Jv7�7 } 9:25,
I certify that I have read this application
FEE a O on 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 hereby authorize representatives of this County to enter TOTAL FEE a
upon the above-inentioned property for inspection purposes
/7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date -