HomeMy Public PortalAbout6212 IVAR AVE_Miscellaneous__ WORKERS'COMPENSATION,DECLARATION CE 875(2-80) M �SC E L LSA N E®U S� A P P U. C'AT 1®N
•Thereby affirm that I-have a•certificate of consent to self "
insAre; or,,a certificate of workers'Compensation Insurance;;or COUNTY OFL;OS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. .•Company FOR APPLICANT TO FILL IN 'BUILDING,`
ADDRESS- .'
Certified copy is hereby furnished. Bu1LDING �"+ i/�/�/ LocwLirY
. ADDRESS ,y /: �Y/•/ _ L CfTT G
F-1. Certified copy is filed with the county building inspection _
de artment. a LOCALITY ��/ r CROSS;ST. �jAp
p I G �P C_ GI `ji 1. NEAREST jl ....�...
Date Applicant NEAREST [ r DISTRICT NO. GROUP /TYPE PROCESSED BY
CROSS ST. &'• �JSSE G�}"L�' � CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS'" LEGAL'
D.ESCR IPTION LOT NO. 'BLOCK MAP HIGHWAY-
COMPENSATION INSURANCE' ST
• . ' (CIRCLE) STATE A'JORS ECOND LOCAL 0-
USE:
NO. OF BLDGS.-
(This section need-not be cot npleted if the work Involved TRACT" 5 o NOW ON LOT USE ZONE SPEC IAL,CONDITIONS' 0
by the .permit is for one..hundred dollars($100) or.less.) _
- USE OF
` SIZE OF LOT'. , S, EXISTING BLDG. •• - - • "�
I certify that in the performance of the work for which this
permit is issued, I shall not employ anyperson-in any manner OWNER' LE f—
as to become subject,to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W .
so ``
. ADDRESS y''y .L VAK
'Date Applicant
TE4. ANT LOAD•FV•
4
ptd -2 . A/}„ z.
NOTICE TO APPLICANT: If, after•making this Certificate of CITY LE.C- T rvo• 0 t0 ''!/`I7 5[, OCCUP —.
Exemption, you should become subject to the Workers' AP LICATI'ON FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with -Comply E
with such .provisions Or this permit shall•be TRAILER USE �' `GEOLOGY INSPCTION'
deemed revoked. ❑ NO Spec: KnOwl. ❑
LICENSED CONTRACTORS DECLARATION ' El
OCCUPANCY INSPECTION
Panic DOVIC@S,
I hereby affirm that.1 am licensed un der'provisions of Chapter SAFETY PER Mir (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 y�,�
effect.. P.oU r�y0 PARKING
SPACES REQ'D PROVIDED,
License Number Lic.'Class
LIMITED.TIME. USE
Contractor Date DATE DATE.
a -
FROM: TO: .. '
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF' rvo,.oF INSPECTOR'S
acting in my;professional 'capacity' (Section 7051•; Bus-. EXISTING BLDG. STORIES SI NATURE
--iness and Professions;Code). FINAL APPROVAL
PRESENT USE.OF BUILDING - �� -
Li
c.or Reg.No: Date
owi4c , occapy
HOME OWNER-BUILDER DECLARATION' , No'. oFtExls USsuwDinics
E
G
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
:23 8-Q 7•A
-•ness.and Professions Code): - NO. PARKING _
# o .
SPACES PROVIDED �j -' 8Q550•
0 I, as owner.. of the property, will do the work and.1he I c,-
structure, is not intended or offered for sale (Section o D D 8'0 5
7044,Business and Professions Code) 'OF. ,
• PROPOSED USEBUILD -
ING _
CONSTRUCTION LENDING AGENCY 0 1.'1 .3 6
--I hereby affirm That •there is a'construction lending agency.
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,1 have read this application and state that the p� ��y .
ISSUANCE FEE < (J -
above information is correct. I agree to comply withallCounty L- -
ordina es and State laws relating to building construction, TOTAL FEE
an a by authorize representatives of this County to enter �'6
u e above-ment' ned prop r.inspectiop p rpose SEE REVERSE FOR-EXPLANATORY LANGUAGE
ignat of Permittee bate