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Home My Public Portal About5816 CLOVERLY AVE_Miscellaneous__ WOR KERS'COMPENSATION DECLARATION CE 87575 (11 84) M I SC,E L LA N E O U S APPLICATION � CE 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) Policy No Company FOR APPLICANT TO FILL IN BUILDING '.D40 A ( ADDRESS Q 2'7 /V)� nC�y)aL 7-6 Certified copy is hereby furnished BUILDING l/ �/ 0LOv ADDRESS LY ,-7: LOCALITY ' �6 �1 /�, I�LpVE7�LY T l7 /� Certified copy is filed with the county building inspection LOCALITY F� // �(I //'� T//7 NEAREST department �I(� �J Z "l . ( yeg� / �` . CROSS ST Date Applicant NEAREST n T d A 3R DISTRICT NO GROUP TYPE PROCESSED BY CROSS ST MS / a-14S AKEZ Q��+�� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' f COMPENSATION INSURANCE DESCRIPTION I LOT NO (J g BLOCK MAP HIGHWAY. NO (CIRCLE) STATE MAJOR SECOND LOCAL NO OF OLDGS (This section need` not be completed if the work involved TRACT / NOW ON LOT �3USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars,($100) or less) usE OF �/J� y//� SIZE OF LOT 5O X/ 7.S EXISTING BLDG !<3 �lC 3 r ' a- 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 14S U v so as to become subject to the Workers' Compensation Laws 91 22 //, OCCUPANCY GROUP °= MAIL -�.Iq�/V3.........,�. _E-�I AI L1� I ^++vC:) ADDRESS (- Date Apphcant w NOTICE TO APPLICANT If, after making this Certificate of CITY T� NO 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl deemed revoked I A I � 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 OF LO �tl�T effect /}C MEPARKING SPACES REQ D E PROVIDED License Number Lic Class LIMITED TIME USE _ Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF INSPECT S TO acting in my professional capacity (Section 7051, Bus EXISTING BLDG STORIES R M SIGNA U E iness and Professions Code) R // [, PRESENT USE OF BUILDING � ,v�Ae20e Ko/T..�� FINAL APPROVAL / /� Lic or Reg No Date /� ✓✓✓ v \XU I vu_ Ns a— ( UIQ AJ17js ABODE, HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGSA&E l ON LOT AND USE -3 - Nome 12 I hereby affirm that I am exempt from the Contractor'si �C o s ) License Law for the following reason (Section 7031 5, Busi 21 P/-,-,x x✓ .3 r ness and Professions Code) NO PARKINGS G4,L�li SPACES PROVIDED i3i� 0 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section - � �� 7044,Business and Professions Code) { ' PROPOSED USE OF BUILDING S{{ME' � }f�� - ti lTAL 93 - 00 CONSTRUCTION LENDING AGENCY r'H£Cu,ii:t I hereby affirm that there is a construction lending agency Ar 17' , for the performance of the work for-which this permit is CHANGE .013 issued(Sec 3097,Civ C) Lender's Name PROPOSED MAX OCC 3 Lender's Address '90 Da �i[I(i—[-d-1�i 1 J`;`-'�'j�i PERMIT FEE 1 certify that I have read this application and state that the I PM :::_4 above Information is correct I agree to comply with all County ISSUANCE FEE 00 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL, FEE -� on the above-mentionedoperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE U;_ Signature of Permittee J Date COUNTY OF LOS ANGELES Utrtw•r r 1�Jr v��-� L�fjL�J�f'{�`JI' Local.- — �J Trac;. No. T:,C No. Lo z E-.--e IsS-ae Da-:e F—al Da DeS=—m =or o; R i _ T-Z-,,e —e Da., gr- a? Daae Da::- (E:—,a— Descr_p z_on of wcrl Sq. F4. PertIssue a.. FI ral Dare Desc__pt_or of w I sq Ft. ' Bui ldl3g Tit ,� Is e Da:a tie .� Descrip-c_on f wo_' Sq. Ft. B ding it Pp� # Issue DaT.e F-=. De ipcion of work Sq. Ft. M Note: The it ornation _ n is aken fr BU lding P----ai-t Records. Unless an Occupancy Inspect ' s regueszed and the fee for this inspection is paid, no investi-patio f the proper-c�' w-114 be made by the s D en ar t-.ent. Sewer Perm t # Issue Date Connected to sewer in street: Inspection Date Senn e i-0 s I COUNTY OF LOS ANGELES -IL DEPARTMENT OF PUBLIC WORKS r r �Ctvtrw ' 11V— 't--� _CFOr �� LTFOPy'r MT01T OW \jo c Record �ea=- 1y Bu_ld-ng Aaaress5-U6 Locali-G Tract No. 00 No A--Lo-u No. Lo-c Size Build-pg Pew t � -ssue Daz2 ,pal Daze12 3 r Descri r z1on of Wor_� Sq. Ft.\ Bui l d, -,- perm, t _- -� tr Issue Daze F��al Daze Description of wcrk Sa . F-u. Buy ldpg Perms t Issue Daze Final Dale Description of 'wore Sq. Ft. Building Permit # 1 Issue Date Final Daze Description of work Sq. Ft. Building Permit # ; Issue Date Final Date - Descri.pti.cn of ;vTork S Ft. Note: The information given is taken from Building Permit Records. Unless an Occupancy Inspection is requested and the fee for this inspection is paid, no investigation of the property W-11 be made by this Department. y Sewer Permit # Issue Date Connected to sewer in street: Inspection Date 1 r