HomeMy Public PortalAbout6012 IVAR AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE$454 (, 84) MISCELLANEOUS APPLICAT0ON
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
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING / ^ J
ADDRESS C/�G//.+/2— //.
Certified copy is hereby furnished. BUILDING - LOCALITY G
ADDRESS C
Certified copy is filed with the county building inspection LOCALITY�I'7���D J c
NEAREST
department. 4/��T �' � 1 CROSS ST.
Date - Applicant NEAREST '/ /� DISTRICT NO. G OUP TYPE PR CESSED BY
CROSS ST. 2 ��1/ - �L( ` Jam+ CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 7. O� -
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
• No. (CIRCLE) STATE MAJOR SECOND LOCAL
' NO. OF BLDGS. '
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit.is issued, I shall not employ any person in any manner OWNER ?'` I`a C—D
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP I=
Date Applicant ADDRESS
TEL. > LU
• NOTICE TO APPLICANT: If, after making this Certificate of clry � L' No�J�? 86 b OCCUPANT LOAD n
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: _
With comply with such provisions or this permit shall be TRAILER USE EJ GEOLOGY INSPECTION SpecKnowl ❑
deemed revoked. ❑. No . .
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 EXITS
ness and Professions Code, and my license is in full force and 1� J
effect. T/'° 1/P/Z.
2'274 D PARKING
SPACES REQ'D PROVIDED
License Number Lie. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered FROM: TO: INSPE T RE
g professional engineer SIZE OF NO. OF sIG TORE
acting in my professional capacity (Section 7051, Bus- EXISTING„BLDG. STORIES
iness and Professions Code). FINAL APPROVAL
PRESENT US" UF BUILDING 6
Lie.or Reg.No. Date q
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS I
ON LOT AND USE - - - -
I hereby affirm that I am exempt from the Contractor's - - AC l o a
License Law for the following reason (Section 7031.5, Busi-
ness
usi a ! iIg e
ness and Professions Code): No. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the I I T Edi'.:i
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL 219 - 75
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING CHECK 19.715
I hereby affirm that there is a construction lending agency Z' .e�.u,e ' vzIle, CHANGE ,Ii0
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name j
PROPOSED MAX. OCC. 0000-0001 11/ 6/92.
..
Lender's Address � ,:,7 F .I AN11:21
I certify that I have read this application and state that the PERMIT FEE 6
'
above information is correct.I-agree to comply with all County ISSUANCE FEE 7
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter ro FEE 2
upon the above-mentioned'pro erty for inspection purposes.
��• �� .6����U �Z SEE REVERSE FOR EXPLANATORY LANGUAGE
ury
`` Signat�e of Permittee Date