HomeMy Public PortalAbout6153 IVAR AVE_Miscellaneous__ WO KERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPL0CAT0ON
CE 875 (11-84)
I l�re�i1,_:nfcert that i have a certificate of consent to c 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 1 FOR APPLICANT TO FILL IN BUILDING / 2
ADDRESS t ✓1
FICertified copy is hereby furnished. BUILDING
ADDRESS F•� LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. / CROSS ST.
Date Applicant - NEAREST DISTRICT.NO.� TYPE PROC ED BY
CROSS ST. ! ` - O�ryy// CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT Ivo. (/Z J�J BLOCK MAP HIGHWAY
rvo. (CIRCLE) STATE MAJOR SEC DLO CAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 5 O NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less. USE OF
SIZE OF.LOT EXISTING BLDG.
I certify that in the performance of the work for which this '` C:)
permit is issued, I shall not employ any person in any manner OWNER - '.,: n -'
so as to become subject to'the Workers' Compensation Laws. R' '
J p MA O;CCUP,ANCY GROUPS <? , o
ADDRESS �� `� --1-.• ., O\'Y 'tl � ,. i' 7 ll
Date. Applicant - U.,
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD
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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know[. Eldeemed revoked. ,
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
effect. ` ' A7610,44PARKING
SPACES REQ'D D PROVIDED
License Number Lie. Class r' LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN TORE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date L7
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS # o a e a 3 Q
ON LOT AND USE -
I hereby affirm that I am exempt from the Contractor's 1 - - 8.0.50
License Law for the following-reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING - 80,505
SPACES PROVIDED "
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section c"��•'x %, .
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency f;." ( �• _
for the performance of the work for which this permit is
issued(See. 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 V I
ordinances and State laws relating to building construction, f
and hereby horize repr sentatives of this County to enter TOTAL. FEE
upon the ab ve- ent�ione ro ty for inspection purposes.
nn� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date