HomeMy Public PortalAbout6233 CLOVERLY AVE_Miscellaneous__ WORKERS'.COMPENSATION DECLARATION CE8754(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of,consent to self COUNTY OF LOS ANGELESBUILDING AND SAFETY DIVISION
insucrp, or a certificate of Workers'Compensation Insurance,or �. .
a cejtified co y there Sec 800,�L`ab.C.)
Policy No. ni Company Ea-- 1 FOR APPLICANT TO FILL IN BUILDING a
ADDRESSf
❑ Certified copy is hereby furnished. V BUILDING �� LOCALITY
ADDRESS
I Certified copy is filed with the county building inspection NEAREST —
dep
qt. LOCALITY i CROSS ST. zl
Date ' Applicant—.tNNEAREST DISTRICT NO• GROUP TYPE PROC SED BY.
CROSS ST. 'q // _Dr`1�ST. /
CE TIFICATE OF EXEMPTION M WORKERS' LEGAL ��'�!!— " }
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. ��N (CIRCLE) STATE MAJOR SECOND LOCAL Q,
NO. OF BLDGS. O
(This section'need not be completed if the work involved TRACT , NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT E 1STING BLDG. '
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 S
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP =43
WMAIL
ADDRESS °����'� V)
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of clrY' NO. OCCUPANT LOAD
Exemption, you should become subject to the Workers' Al APPLICA ION 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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ .
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L J (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
AA 0 0effect. PARKING
SPACES REO'D PROVIDED
--
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
❑ I am exe t from the-licensing'requirements as I am a.
/J„' N- / (NSP CPU"
licensed architect or a registered professional engineer SIZE E V F ST IE r/{7�f�y���! (y��
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES �/ .�Ll" �'CaYa-+y�5'IGNrA U1tE ,
T-iness and Professions Code). FINAL APPROV OVAL n /l
PRESENT USE OF BUILDING /�' 457 �'
<---
tic.or or Reg..No. Date
HOME OWNER-BUILDER DECLARATION NO. OF Ai DEisUNG BUILDINGS
ON LOT AND USE
I hereby affirm that I am 'exempt from the Contractor's z 8 6 5 7 A
License Law for the following reason (Section 7031.5,-Busi-
ness.and Professions Code): NO. PARKING #'0 0:0 0 3
SPACES PROVIDED 0
❑ I, as owner of the property, will do the work and the 21 - 8050
structure is not intended or offered for sale (Section ° °
7044, Business and Professions Code).
PROPOSED USE OF BUILDING - f0 0 0
8,0,-5 O'U
CONSTRUCTION LENDING AGENCY
I Hereby affirm that there is a construction lending agency 22 9-82
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 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
ordinancesand State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County to enter e Sed
upon the above-mentioned property for inspe ion pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o mittee Date