HomeMy Public PortalAbout6012 CLOVERLY AVE_Miscellaneous__ WORKERS'COMPENSATION DECLAF ATION
CE 875 (11 84) MISCELLANEOUS APPLICATION
CE 875
I Rereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished BUILDING �n � p `'
ADDRESS 1,'/a Y, 1 !V LOCALITY
Certified copy is filed with the county building inspection LOCALITYJ NEAREST
department I {�L 1 •- CROSS ST
Date Applicant NEAREST // DISTRICT N G p TYPE P O SSED BY
CROSS ST /_ IF) CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION 114 N I BLOCK P HIGH
NO (CIRCLE) STATE MA OR ECOND LOCAL
B
(This section need not be completed if the work involved TRACT NONOWOF LD 65 ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) i USE OF
fiX
I certify that in the performance of the work for which this SIZE OF LOT (STING BLDG a
permit is issued, I shall not employ any person m any manner OWNER �� �� ��� K A00 y
so as to become subject to the Workers' Compensation Laws
MAIL OCCUPANCY GROUP
�� L-p_ if „/
ADDRESS �/{J /�/ �
Date Applicant v
NOTICE TO APPLICANT If, after making this Certificate of CITY CNS p� �j-r NOLj•� 2� OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLI ATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECT[ N
Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PER MI (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 Lic Class LIMITED TIME USE
Contractor Date 10, DATE DATE
I am exempt from the licensing requirements as I am a FROM 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 SIGNATURE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date PRESENT USE OF BUILDING //
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGSll
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's T.a
License Law for the following reason (Section 7031 5, Busi- ;it i- a I-Il
ness and Professions Code) NO PARKING -� -
I, as owner of the property, will do the work and the SPACES PROVIDED I _TEM_'
structure is not intended or offered for sale (Section
u _,
7044,Business and Professions Code) 1!I(fiL 83 m 0O
CONSTRUCTION LENDING AGENCY PROPOSED USE: of BUILDING (,HE
I hereby affirm that there is a construction lending agency aIn��t3�
for the performance of the work for wluch this permit is
issued(Sec 3097,Civ C)
Lender's Name I _
• PROPOSED MAX OCC 00.39-b'D 0j, tlJi 1l7y)
Lender's Address ��,;;
�`ia ,SII La 11
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,
and hereby authorize representatives of this County to enter TOTAL FEE
upon a ve-me do d operty Pr inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of P tee Date