HomeMy Public PortalAbout5822 CLOVERLY AVE_Miscellaneous__ WORKERS_CTPENSATION DECLARATION
CE 875 (11 84) MISCELLANEOUS APPLICATION
CE 875
I heretJy af£ir-i 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 FI LL IN BUILDING 2�
ADDRESS
Certified copy is hereby furnished BUILDING tj ,� LOCALITY
ADDRESS ..�..d/
Certified copy is filed with the county building inspection LOCALITY / NEAREST
department \/ cRoss sr
Date Applicant NEAREST DISTRICT 110CROSS ST G UP TYPE PRO E ED BY
�y CON$T�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ^ '5^ o
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
rvo (CIRCLE) STATE MAJOR SECO LOCAL
NO OF BLDGS i
(This section need not be completed if the work involved TRACT NOW ON LOT / USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) i+ USE OF /f,��
SIZE OF LOT EXISTING BLDG /1-+��•'
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 Z
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o
ADDRESS
Date Applicant LULL
NOTICE TO APPLICANT If, after making this Certificate of CITY THE 14 OCCUPANT LOAD
Exemption„ you should become subject to the Workers' APPLIC15,TION 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
EJ
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 /3
effect PARKING REQ D PROVIDED
SPACES
License Number Llc Class
LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a
M 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 / IG ATURE
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
LIC or Reg No Date , G
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS /
ON LOT AND USE 6 4 3,6 A
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 PARKING # ° ° ° ° 3
SPACES PROVIDED I
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section _� °�°�8"Q 5�0
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING — _+° ' $ 5 v
I hereby affirm that there Is a construction lending agency ,� - �{� 2 9—87,-_
for the performance of the work for which this permit is J `
issued(Sec 3097,Civ C)
Lender's Name
PROPOSED MAX OCC
Lender's Address
PERMIT FEE
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
ordinances and State laws relating to building construction, nV(J 1 1
and hereby authorize representatives,of this County to enter TOTAL. FEE 1 \
upon the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date—T