Loading...
HomeMy Public PortalAbout6201 IVAR AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11 84) MISCELLANEOUS APPLICATION CE 875 I hereby 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 FI LL IN BUILDING ADDRESS Certified copy is herebyfurnished. BUILDING ��® � ' ADDRESS J- LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. tv CROSS ST. Date Applicant NEAREST DISTRICT NO. Cy�OUP : TYPE PRO E SED BY CROSS ST, �.V ,fir 2 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ,YY` COMPENSATION INSURANCE DESCRIPTION I LOT NO, BLOCK MAP HIGHWAY NOOF BLDGS. NO. (CIRCLE) STATE MAJOR SECO D LOCAL . - (This section' need not be completed if the work involved TRACT NOW ON LOT US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. r I certify that in the performance of the work for which this V ` o permit is issued, I shall not employ any person in any manner OWNER J raj VA" y so as to become subject to the Workers' Compensation Laws. IL/,4R ' OCCUPANCY GROUP � ADDRESS6A0/ I(� R V� Date Applicant LU NOTICE TO APPLICANT: If, after making this Certificate of CITY C tUI NO -��d �g'2S OCCUPANT LOAD r°„ Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION Eldeemed revoked. El ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I& 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 P Y effect. �/4fZ L{f 42�� S B/ / PARKING SPACES REQ'D I I PROVIDED ' LL_��JJ License Number Lic. Class 6-r D LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NoFROM: TO: . of INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie.or Reg.No. Date I,J d rh Shap HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING � property,y' V M 2624 4 A I, as owner of the ro ert will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section '}�;0 0 0 0 3 0 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING \ ( 0 - 80. 50 I hereby affirm that there is a construction lending agency do-" ' V ` Q{ /pp, o o•0 8 Q 5 0 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name ;1 2 3 1 =86 PROPOSED MAX. OCC. Lender's Address 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 ord' ances and State laws relating to building construction, OA and reby authorize representatives of this County to enter TOTAL. FEE upo le abov 7t;iZd property for inspection purposes. 17 SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Perm to Date WORKERS'COMPENSATIONDECLARATION 76M444 pA ���II-p p R� AIIC®4J�� �P�ILO�Y�i��®� CE 875 (11-84) M E LILi'�N E I hereby a cert that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Worker s'.Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING ✓, ADDRESS r/ Certified copy is hereby furnished. BU"DIN s -ZO CLII LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. , 1 CROSS ST. Date Applicant NEAREST ^ DISTRICT NO,, OUP TYPE PROCE 5ED BY CROSS ST. �.0 ,IIS' 7 CONST., CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL n COMPENSATION INSURANCE DESCR'IPTIOry LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECO D LOCAL ' NO. OF BLD 65. (This sectlon,'need not be completed if the work involved TRACT NOW ON LOTUS ZONE SPECIAL CONDITIONS by the permit is for one hundied dollars ($100) or less.) USE OF SIZE OF LOT v X 5 EXISTING BLDG. D_ I certify that in the performance of the work for which this v o permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY.GROUP MAIL ) 7-L //� '7 i O ADDRESS6,o/ d-L AR �(� � Date Applicant TE p� �cL LU NOTICE TO APPLICANT: If, after making this Certificate of CITY C No 'ty.�.�d —O��S OCCUPANT LOAD �°„ Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ ❑ E] 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 ❑ (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: C-j/14�7� W©2�� _5141.4p 1-"-9 PARKING ' SPACES' REQ'D D PROVIDED License Number Lie. Class LL�� LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a . licensed- architect or a registered professional engineer SIZE OF NO. OF PROM• To. INSPE CTOR'S acting m my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES GNATURE iness and Professions Code). FINAL APPROVAL (/ PRESENT USE OF BUILDING Lie.or Reg.No, Date � 1N d r/S $h o HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS wo /ON LOT AND USEI hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING V SPACES PROVIDED property, V 6 2 4 4 A I, as owner of thewill do the work and the i7 structure is not intended or offered for sale (Section #:0,0 0 0 7 0 7044,Business and Professions Code). /` �J " CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING `(� ( :'I D ® 8 0. 5 0 1 hereby affirm that there is a construction lending agency L1pn o a{ r o aill S 0 J� 0 u for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). ,2,3 1 8 b Lender's Name PROPOSED MAX. OCC. Lender's Address - Icertify 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 ord' ances and State laws relating to building construction, and reby authorize representatives of this County to enter TOTAL FEE upo e abov ti d'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Si ature of PermVteV V Date .. COUNTY OF LOS ANGELES 1-: 'Re ccor3' Search in.'Lcrma .. ion ?uJLldinc Address Locality Tract No . S___ Lot No . 23 Lot Size _5 ssue Da-e 136 Final nal E;&+ e Description of work Sq. Ft . 3G Building Permit # Issue Date a Final Date_(� _eZ6'A Description of work_ Sq. Ft _uildinE_ Per:T.it Issue Date /.ZZ2 Final Date 11-2- _LZ J-L') Description of work Sq, Ft , Building Permit # Issue Date Final Date Description of work Sq. Ft. NOTE: The information given is taken from Building Permit Records. Un- less an Occupancy Inspection is requested, and the fee for this inspection is paid , no investigation of the property will be made by this Department . Sewer Permit # Issue Date Co.nnectej to sewer in street : Inspection Date benior ClerK