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Home My Public Portal About5759 CLOVERLY AVE_Miscellaneous__ laICKER}COMPENSATION DECLARATION 7MISCELLANEOUS APPLICATION 875 CEE 875 (11 84) I ,� rebs of lrm that I slave d certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insdra,'or a'certlflcate'of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) BUILDING Policy No Company FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished BUILDINGADDRESS J 1 ��L L+ v 1 LOCALITY ECertified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant NEAREST VN NO GIII��OOOUP TYPE P SSED BY CROSS ST S Lc�•S ' J ON I /I(/ � CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (Jo COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY �7 NO (CIRCLE) STATE NO OF BLOGS MAJOR SE ND LOCAL (This section need not be completed if the work involved TRACT NOW ON LOT US `ZONE SPECIAL CONDITIONS b the permit is for one hundred dollars ($100) or less) C I I certifythatin the performance of the work for which this SIZE OF LOT SDX i 3 EXISTING BLDG C N a 0 permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws DS MAIL 5 75 G i ev P r OCCUPANCY GROUP o ADDRESS \ ~ Date Applicant LULL NOTICE TO APPLICANT If, after making this Certificate of CITY TfIiM t NOL QaZ 7-fpa 7 a 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 OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION 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 GAG D� P -�� Q x G PARKING effect REQ D PROVIDED SPA CLS License Number Lic Class ✓1IDy-A. \ 1 -e- Ry-0f 0� 7O oV\ 30 +- 39 ears a p LIMITED TIME USE Contractor Date DATE DATE FROM TO 0 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 SIGNATURE mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lie or Reg No Date 5. ^ l i ok vA 11, o vA e HOME OWNER-BUILDER DECLARATION NO OF EX TING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING6 3(7 4 A El I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section ° ° ° 03 0 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ° ° 8 G 5.01 I hereby affirm that there is a construction lending agency , e ° ° 8 0 5 0 6 for the performance of the work for which this permit is issued(See 3097,Civ C) �,L 0 i 8 7 Lender's Name PROPOSED MAX OCC Lender's Address W I certify that I have read this application and state that the PERMIT FEE above information is correct I agree to comply with all County ISSUANCE FEE J I S ordinances and State laws relating to building construction, d herb u orize representatives of this County to enter TOTAL. FEE p n t me ed property for inspecti n pure ses 1 -2,0 ,� �� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ( Date _ 64 COUNTY OF LOS ANGELES . DEPARTMENT OF PUBLIC WORKS r—TCROFI I"I MORMA-TION �c Record Search from 1933-1954 Building Address Sq , f�',`� \�� I,ocali tc Tract No. «)�((j` 100-C No. 07 Lot Size 50 X�q() Building Fermi t ,- �� Issue Date91ZZ inal Daze .L S J4 Descries pion of work ��;� �� (`i (�1�V�� ( �� \ Sc. Fv.q•(n`) , I - � y ^ r "`� Iss'ae Date `� �(��-�a1 Daae Description of wor+r So. F Building Permit m Issue Dace F-inal Daae Descri-ption of worir S c. Fi.. Building Perini- Issue Daze F---allDare Descr=Ilz1on of woT_"r Ea. Fes. Building Perm_- Iss,ze Date F;-nal Date Descrirti cn of wor'k- Noce . Tie ?ro-"tea-=OL g-- Te'r i S Zv' ak�n frE Build--ng Fe-, Records.,,�- E�O.ds. jJIl1eSS am Occu-par'cy, 1=S7:;ec-=oT._' is reques-e, and -ne fee for zits —spe^.icn 1S paid. no T v eS-1,azioT? of zhe -D='operty W1ll be made by tom` - s Dec a.rtze=u. Se.,rer reg m issue Date Cornec-ed tc sewer -, ,i sz=eet. Inspection Daze 51,zz) C I S ti• _..i _" ,%'� ' " ' rye ..' ` P a d " i7• ri e "COUfZTY OF AWAMLES ` h Vf <xS", - s�71.�i.'=��►� of fR:.: W.M. a # /J �ddrES: S 7S I` Locality :ra c Let o. Al a C Lot Sigel ,So X �-r Description of work_ 9L I-AA ell Pui;ding Fermit Issue Date Final Date Df :crap:i--n of word- Sq. Ft . Issue Date =:r :f Description of work o Sq. Ft , Suild:rg Permit Issue Date Final Date Description of work Ar W 0- NOTE: The information given is taken from Building Permit Records. Un- less ars Occupancy Inspection is requested, and the tee for this Inspection is paid , no investigation of the property will be zade v by this Department. Sewer FFrmit r issue Date tr• atwer in *:rfet : inspection Date ! . . x ''4 nrs " �AlOT Er .`,