HomeMy Public PortalAbout5848 CLOVERLY AVE_Miscellaneous__ { I WORKERb (.UMVt,INJAttUIN UCk,LAKAIIUIN 20-0063DPW12/90 iril��..tLLHI�IIGVU.> Hl"'t'L1L.H1 1V111
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION II
insure, or a certificate of Workers'Compensation Insurance, or u
a certified copy thereof (Sec 3800, Lab C)' :
Policy'No Company FOR APPLICANT TO FILL IN BUILDING
BUILDING ADD E S V ADDRESS
❑ Certified copy is hereby furnished
C
ElZIPCertified copy is filed with the county building inspecttoCITY LocnuTY
{ departmentNEAREST
0 CROSS ST
Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY }
CONST a
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO C
COMPENSATION INSURANCE MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS 09
by the permit is for one hundred dollars ($100) or less.) C
t I certify that in the performance of the work for which th TYt7��r1r er ' TEL No Q
permit is issued I shall not employ any person In any manne W
I so as to become subject to the Workers' Compensation Laws A DRESS OCI a
CUPANCY GROUP
( I Date Applicant TY zIP —
NOTICE TO APPLICANT It. after making this Certificate (O OCCUPANT LOAD
of Exemption you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE
I I comply With such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑
revoked
LICENSED CONTRACTORS DECLARATION , OCCUPANCY INSPECTION EI Panic Devices ❑
I hereby affirm that I am licensed under provisions of Cha re SAFETY PERMIT❑ (LIST ITEMS BELOW)
t I 9(commencing with Section 7000)of Division 3 of the Bu;in s ame o us ess No OF EXITS
and Professions Code and my license is in full force and etfe t
PARKING REO'DD PROVIDED
i License Number Lie Class � V SPACES
t i I Contractor Date LIMITED TIME USE
I ❑ I am exempt from the hcensi ng requirements as I am aDATE DATE
licensed architect or a registered professional engineer FROM To
{ acting in my professional capacity(Section 7051,Business SIZE OF q� NO OF INSPECTOR'S
' I and Professions Code) EXISTING BLDG STORIES SIGNATURE.
Lie or Reg No - Date PRESENT USE OF BUILDING �Y R FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
i ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 70315, Business and
l Professions Code) NO PARKING
❑ I, as owner of the property, will do the work and th PAGES PROVIDED
structure is not intended or offered for sale(Section 704Qi OPOSED USE OF BUILDING
Business and Professions Code)
i CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
i (Sec 3097, Civ C) PROPOSED MAX OCC.
Lender's Name I
(CANT IPRWT _ TEL NO
Lender's Address DDRESS
( i I certify that I have read this application and state that % L
- cwiou
above information is correct I agree to comply with all CoRMIT FEE
I ordinances and State laws relating to building construction,
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentione prope for inspection purposes
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pert tee Date