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Home My Public Portal About5850 CLOVERLY AVE_Miscellaneous__ _ r NORKERS'COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION 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 , I "fl a certified copy thereof(Sec 3800,Lab C) BUILDING Policy No Company FOR APPLICANT TO FILL IN ADDRESS I Certified copy is hereby furnished uILDING S�Ss"�' C L17 LSE R� �rl✓ LOCALITY ADDRESS Certified copy is filed with the county building Inspection NEAREST department LOCALITY -re-177loLL C T y CPLD r CROSS ST Date ApplicantAREST ��ii ^' /� DISTRICT NO G OUP TYPE PROCE D Y LO CROSS ST L P S r e-)/V�r� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MwP HIGHWAY STATE MAJOR SECOND LOC L NO OF BLDGS NO (CIRCLE) d (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less) USE OF 1 SIZE OF LOT EXISTING BLDG C/ ' Ir I certify that Ithe performance of the work for which this O permit Is Issued,, I shall not employ any person in any manner %.'tWNER �� R � C so as to become subject to the Workers' Compensation Laws /nom ` / ( OCCUPANCY GROUP U JJ1AD1 IL PD. IJ 1l fO J+ W DRESS d Date Applicant S co NOTICE TO APPLICANT If, after making this Certificate ofTYGOL2)1f/`L PENOL �� 2 OCCUPANT LOAD Z Exemption, you should become subject to the -Workers' Compensation provisions of the Labor Code, you must forth A PLICATION FOR EXIT HARDWARE With comply with SUCK prOVISIOUS Or this permit shall be TRAILER USEGEOLOGY INSPECTION NO Spec Knowl deemed revoked _ ❑ Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT [� (LIST ITEMS BELOW) No of EXITS 9 (commencing with Section 7000) of Division 3 of the Busi ness and Professions Code, and my license Is in full force and ePARKING effect SPACES REO D O PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ED I am exempt from the IlLensmg requirements as I am a FROM T licensed architect or a registered professional engineer SIZE OF NO OF I SPECTOR S acting in my professional capacity (Section 7051, BUS- EXISTING BLDG STORIES SIGNATURE iness and Professions Code) p ENT USE OF BUILDING FINAL APPROV PCL 93 9, 3 93 A Lic or Reg No Date CAU Y P L[I�V • ob-fib HOME OWNER BUILDER DECLARATION NO of EXISTING 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 PARKING ) SPACES ACES PROVIDED h El1, 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 �• 9 S`/D�" OPOSED USE OF BUILDING a� CONSTRUCTION LENDING AGENCY /]��U � �/ S 19.i1�Q Al I hereby affirm that there is a construction lending agency / for the performance of the work for which this permit is Issued (Sec 3097,Civ C) Lender's Name PROPOSED MAX OCC Lender's Address r 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, TOTAL FEE and hereby authorize representatives of this Cou to enter ' upon a above mentioned property for insp �1ion purposes , SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 87 5(1 1 84) MISCELLANEOUS APPLICATION I hereby affrim that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION msu:Y, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS V Certified copy is hereby furnishedBUILDING LOCALITY G ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant ANEAREST DISTj21CT NO OUP TYPE PROCESS D Y CROSS ST J` CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY NO (CIRC,.) STATE MAJOR SECOND LOCAL (This section need not be completed if the work Involved TRACT NO WOON LOT 3 USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) I USE OF SIZE OF LOT EXISTING BLDG / d I certify that in the performance of the work for which this �J o permit is issued, I shall not employ any person m any manner OWNER 0 so as to become subject to the Workers' Compensation Laws MAIL f OCCUPANCY GR�OUP_,� IC:) "ADDRESS 8 Date Applicant _ W I TE L NOTICE TO APPLICANT If, after making this Certificate of CITY V6L � j 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 useGEOLOGY INSPECTION ❑ ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI (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 SPACES REQ D D PROVIDED D License Number Lie Class LIMITED TIME USE Contractor Date DAT. DATE R M TO I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer slzE of No of INSPECTOR 3 acting m my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES S GNATURE mess and Professions Code) ;r C ,O FINAL APPROVAL ) LIC or Reg No Date PRESENT U36 OF BUILDING Oi/� c� HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGSI FEE 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 PARKING r --IMI 6/19/ ❑ 1, as owner of the property, will do the work and the SPACES PROVIDED 4W 1 PM W. structure is not intended or offered for sale (Section �� 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec 3097,Civ C) B �f Lender's Name PROPOSED MAX OCC Lender's Address d� 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 ordinances and State laws relating to building construction, 5 and hereby authorize representatives of this,County to enter TOTAL FEE up the bove- entioned pyo erty fnspect n purposes SEE REVERSE FOR EXPLANATORY LANGUAGE L-15ignature of Iliermittee Date i E, / rt i ISl I hereby affirm :hat I have a :e::iicate )f .:onse•:: :JeZ - insure. or a certifieateof'Aor`ers'Compensariun insiilanc:. .r l GC "TY OF LGS -ANG-LES BUILDINGAND SAFETY DIVISIGN a certified copy :hereof iSec. -SOO. L-,b.C... — Pciic;. vo. Company �r?_ C.-V- _ _ au ..D NG `O� ` I OR ESS Certified copy is hereby furnished. l 3U 1'---!NG ❑ X:c i ZDDR ESS j LOCAL.: Y Certified copy is filed with:he count;:buudine inspectionry i iLOCAL:T`� NEAREST department. i!JZ =Ross ST. er Date Aoolicant NEARES- ' SIS-RIc- N Zi P T�PE c=ssEo ar ICON sT. CERTIFICATE OF EXE_''IPTION 1 ROTI IVORKE R� -_GpL �O(/ i CONIPENSATIO` iNSL:R-iNCZ DE3c�!PT,oN -- IC. 3LOC C —' •Ic. c:wC__( 5-..._ •-IA:CR SECOND '_OCAL _ •JC. JF 3LJG (This section need 5. not be completed !t the work invoivec '7A NO':: O.N '_O. !VSE _ONE'SPECIAL ZONDITIONS by the permit is for one hundred doilars (SlOO) )r less.. _ V _,F _ I :ertify that in :he performance if :he work, - _ 'V;21_ -!IIS =:<��. .. 3uc. permit is issued. i mall not employ anv erson i.^.,r.1 aan..:. ! p.•v-JET ,; ' { j so as to become subiec: :o :he Wor ers• Comcensa:!on L_nv- . _ Rcup Date aociicant _.R NOTICE TO .-kPPLrC.\NT: If, ai:er mai-;- -..s ._. i 7 IYd e ,CNV 7 D E•empti,on. you ,::ouid become bie.: G� CJmpensatlon nrovis-.ons Jf :ire Labor• de. ;,>� . :u: _- = - ---�':: =. wit!,. :omciv with Su:h _:o =;urs Jr -:.._ -ern..: — deemed: OA2d. ___-._.. — NIC -'?C. L10ENSED N7'Z ._-CRS DEC_-'° I Ile:eby ifrirnt .! .:;n '-ice^Sac g commen-cm.,.: •e .. =e_ :o:: -000' Hess in' ':oiess:. iz. _.. _ e...r, L:c_n52. i 17 Licensed 1I:.:i:__ Jr icing In :n essiu c -=_ --.. = E z L. vsPE=-OR -.ess_r•.c M i :Ierebv am I ice.^.5e L1«'.-Or -ire`-JL:.•.t''nz -___,n ___-._.. Hess Ind P:0[25510 n5 Code!: Rs_ nI. IS OW-je• __ -lie Jre . 7044.3usiress Ind ?:Jiessicrs L:. CON 437, LE\?f\6 tl =. I hereby' affirm ..•a_ -Ile': i5 '_ i for [Ile :?Id ! ;Slued,SeC 'OO-. L2nCe:•i`1me / I Leader's Address I I ce.tiiv that I have read -his acciir..on inn -,:i: - -_" - _ �5 0 0 above information is correct. I_,gree :o comely .vi:::.a ssU Auce tee= ordinances and Stare laws reiatirg to buiidin;and I.lerebv authorize recresentatives of :his Coun-v :o enre: TOT A L FEE 2 5 - 0 0' upon:he above-mentioned property for inspection:u:^uses. / !// SEE ZEVERSE 1-0.0 EXPL.3N.k-OR`. L.a�GC kG- �, XXL XX O Gp Si, azure of Permittee Da