HomeMy Public PortalAbout6231 IVAR AVE_Miscellaneous__ - ro1�sPE1+i PION DECLARATION CE 875 M I SC E L LA N E, U S A P P U C AT I O N
CE 875(11-84) I�u (�,/ I�
Wrefix tat•Nhave a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
, cert _'ate of Workers'Compensation Insurance,or
a certified copy themof(Sec. 3800,Lab.C.).
Policy.No. I CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS ',4 azra4 Alt
Certified copy is hereby furnished. BUILDING / �3 ,A �r� LOCALITY
ADDRESS lf7 V/• -
0 Certified copy is filed with the county building inspection LOCALITY �'_I / NEAREST
department. �cy�r'1l �e (! CROSS ST.
Date Applicant NEAREST DIS TIRJ T_{y(�' GROU' TY PROCESSED BY
CROSS ST. J /)Ay CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. u`' BLOCK MAP HIGHWAY
NO. F BLDGS.
NO. (CIRCLE) STATE MAJOR SECO LOCAL
(This section need not be completed if the work involved TRACT NOWOON LOT ' USE ONE SPECIAL 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 ®j( I EXISTING BLDG4w o
141permit is issued, I shall not employ any person in any manner OWNER � ps j i7�} C�
so-as to become subject to the Workers' Compensation Laws. MAIL /� , OCCUPANCY GROUP a
Date Applicant ADDRESS 6• �
TEL' I is OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY G`jy No. 28(0 330rj -(°t7 z
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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
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 ander
effect. OwAtPARKING REQ'D
SPACES PROVIDED
Q
License Number Lic. Class IS
�i LIMITED TIME USE
,'}
Contractor Date w v sh DATE DATE
FROM: TO!
El I am exempt from the licensing requirements as-I am a
licensed architect or a registered professional engineer !i SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL �J
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ;2 8 3 9,8 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.,PARKING # °.° ° ° 3.0
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section ° ° 8050
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ° ° °80 -00
I hereby affirm that there is a construction lending agency I'�,2 0;-_ 8 7
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
I ..
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
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon t above-me tion property for inspection purposes.
J, SEE REVERSE FOR XPLANATORY LANGUAGE
Sig ure of Permittee / Date