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Home My Public Portal About5015 DOREEN AVE_Miscellaneous__ WOi11EERS ,�OMPEN SATION DECLARATION CE 875 _ MISCELLANEOUS. APPLICATION {� .,� CE 875 (2-801 LJ I here444 by 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 a certified copy thereof(Sec. 3800, Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN euuDlec !/ ``ms�sx ,� ADDRESS (l F1Certifiedcopy is hereby furnished. noow Ess JQ� ' c{/ylf/re CC/v c LocwurY ❑ Certified copy is filed with the county building inspection NEAREST department. - LoewurY cM• L.� ��. cRoss sT. Date Applicant NEAREST DISTRICTJ'1 G UP TYPE PR EE BY CROSS ST. ��,L CONSTI I _ CERTIFICATE OFEXEMPTION-FROM WORKERS' LEGAL V J �/ DESCRIPTION LOT NO, BLOCK } COMPENSATION INSURANCE """° �� HIGHWAY STATE MAJOR SEc D LOCAL 1 (This section need not be completed if the work involved TRACT ND. of eLDcs. • O 'NOW ON 40T USEr ZONE SPECIAL CONpIT10N5 U by the permit is for one hundred dollars ($100) or less.) US of _{.. SIZE OF LOT - 'EXISTING BLDG. cc 1 certify that in the performance of the work for which this O permit is issued. I shall not employ any person in any manner owrvER C" U so as to become subject to the Workers' Compensation Laws. MAIL �• ,OCCUPANCY GROUP ,°K^ .W AO DRESS $ Date Applicant l NOTICE TO APPLICANT: If, after making this Certificate of CITY_ K TEL jeje3 r—'"I OCCUPANT LOAD Z Exemption, you should, become subject to the Workers' 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 VSE`] GEOLOGY INSPECTION C3 No Spec. Knowl. ❑ deemed revoked. - LICENSED CONTRACTORS DECLARATION occ......INSPECTION Panic Devices ❑ I hereby affirm that I-am licensed 'under provisions of Chapter, SAFETY PERMIT q (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 effect. PARKING SPACES REO'O D PROVIDED D License Number Lie.Class LIMITED TIME USE ' Contractor Date D.Tc OAT' am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE of No. of , INSPECTOR•$ acting in my professional capacity (Section 7051, Bus ExlsrlNe BLDG. -OR SIGNATURE mesa and PI'Off:5s10nS COdC). PRESENT USE OF BUO'D.NG FINAL APPROVAL 70 [J Lie.or Reg.No. Date t/ [f 8A NO:OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION ON LOT AND USE # • • • 0 4 O 1 hereby affirm th5r I am exempt from the Contractor's I a 8 Q 5 Q License-Law for the following reason (Section 7031.5v, Busi- ness and Professions Code): No..PARKING F-1 ) SPACES PROVIDED , 1, as owner of the property, will do the work and the - 8(150 structure is not intended ur offered for sale (Section 7044, Business and Professions Code). - 0 Q 3 O j 8 5 ' PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency d06e se for the performance of the work for which this permit is issued (Sec. 3097.Civ.C.). ' Lender's Name - PROPOSED MAX. OCC. Lender's AddressPERMIT FEE - ' • U.0 I certify that I have read this application and state that the Ua r—,V1 above information is correct. 1 agree to comply with all County ISSUANCE FEE - ordinances and State laws relating to building construction, A and here p authorize representatives of this County to enter TOTAL FEE V , SO— upon above-mention it pr.perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Permitte at WORKERS'COJIPENSAT!ON DECLARATION CE 875 (1184) MISCELLANEOUS APPLICATION CE 6]5 1 hereby affirm that I have 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.). BUILDIN B. S 0 / S IV ID Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ) oY�e11 Certified copy is hereby furnished. BUILDING s01s/yuo ref Ave LOCALITY T'-- N ADDRESS DCertified copy is filed with the county building inspection LOCALITY .� �'� NEAREST k 1_ department. / e i Q I cRoss sT. (�( s f Date � � Applicant NEAREST �) ¢ DISTRICT NO. GROVP TYPE CE95ED BY CR09S ST. a Ll/2.J C'-O� CON9T.� CERTIFICATE OF EXEMPTION FROM WORKERS' 'LEGAL tt,cE) J COMPENSATION INSURANCE DEscRlPn ory LOT NO. Z BLOCK C N mR.. Nov ZOJC1 Ici cLe) STATE MAJOR SECOND LOCAL /� �jI NO. OF SLOGS. (This section need not be completed If the work involved TRACT L 8O NOW ON LOT USE ZONE SPECIAL CONDITIONS 4 by the permit is for one hundred dollars ($100) or less.) r�p uSE of lru SIZE OF LOT 72 x O Y EXISTING BLDG. I certify that in the performance of the work for which this dC_ permit is issued, I shall not employ any person in any manner OWNER /J SD so as to become subject to the Workers' Compensation Laws. fin �' fe Y}eZ OCCUPANCY GROUP ✓-3 D= MAIL ,'t AO OR E99 D I '/b YQ�1.r VL V Date Applicant uJ TEL 'OCCUPANT LOAD D- NOTICE TO APPLICANT: If, after making this Certificate of CI4Y /p e_ CI NO..rlx)Vll-3y Z7 C_ Exemption, you should become subject to the Workers' IAPPLICATION FOR EXIT HARDWARE: z 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 0� Panic Devices 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 EXIT. ness and Professions Code,and my license is in full forceand /�77 ((}} _ _ effect. LiVl ti /•e tDI..A Wn- fLe J+ V svwe ssG wE0'D PROVIDED License Number Lic. Class F F I Q - `/ — 0� LIMITED TIME USE Contractor Date + &V 4-+ to IL DATE o.Te I am exempt from the licensing requirements as 1 am a .360 �sG licensed architect or a registered professional engineer SIZE OF / ST E / INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLOB. 132 1L r+ STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL /� Lic.or Reg.No. Date � % i 1 N /•._ / � fl _ f HOME OWNER-BUILDER DECLARATION NO. OF zlsnrvG BUILDINJM. 1 ON LOT ANO USE _ 1 hereby affirm that I am exempt from License Law for the following reason (Section 7031.5, Busi- J,--,*�I7 ness and Professions Code): NO. PARKING rV I, as owner of the property, will the work and the ? 1cfi' structure is not intended or offered SPACES PROVIDED d for sale (Section 7044,Business and Professions Code). i iJ iii! i - s 75 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction lending agency /✓/y �Y�CL` J.0""l�i-' for the performance of the work for which this permit is - E issued(Sec. 3097,Civ.C.). Lender's Name '1 PROPOSED MAX. OCG Irl ll_I�—I lt.111{,E Lender's Address - ' PERMIT FEE I certify that Ihave read this application and state that the HI above information is correct. 1 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 /5 upon the abo'-menC//%'ppned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature oC Permittee Dae