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Home My Public Portal About6415 LIVIA AVE_Miscellaneous__ 1) 1VOR�CER'S'COMPENSATION DECLARATION CE 875 (11-84) -Qi' CE 875 M I SC E L LA N EO U S APPLICATION {� Ll I hereby -In that I have a certificate of consent to self insure, or a aificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAF TY IVISION a certified cop7i'•greof(Sec 3800,Lab Q. Policy No. _Company FOR APPLICANT TO FILL IN BUILDING ADDRESS (� Certified copy is hereby furnished. BUIDRLDING �' E ^� / LOCALITY ESS ADt ElCertified copy is filed with the county building inspection LOCALITY IF NEAREST department CROSS sT. Date Applicant NEAREST DISTRICT NO. I WUP TYPE O SSED I?Y CROSS ST '0 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP .,IOR L Y NO./J ZGS (CIRCLE) STATE MAJOR SECOND LOCAL NO OF BLDGS. (This Section need not be completed if the work involved TRACT NOW ON LOT US ZONESPEC IAL CONDITIONS by, the permit is for one hundred dollars ($100) or less.) USE OF sizE of LOT EXISTING BLDG. I certify that in the performance of the work for which this 1 � C!) permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws MAIL / OCCUPANCY GROUP o ADDRESS CP`�"ISVI� G ~ Date Applicant L` NOTICE TO APPLICANT- If, after making this Certificate of CITvT:� rTio� �$OibJ � OCCUPANT LOAD Exemption, you should become subject to the Workers' A PLICATION 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. Knowl. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El 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 't effect. 1JT IFAmlt� f�v m PARKING SPACES REq D PROVIDED License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE ❑ 1 am exempt from the licensing requirements as I am a FR M TO licensed architect or a registered professional engineer SIZE OF ] NO. OF INSP,ECTOR'S g g l u I �/ "S�GNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. X STORIES mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING i Lie or Reg No. Date v 171 HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDI s 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. PARKI I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). ' PROPOSED USE of BUILDING 5 51.4 Ll A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency # 0 0 0 0 30 for the performance of the work for which this permit is issued(Sec 3097,Civ C). 1 -,,- 8050 Lender's Name PROPOSED MAX. OCC. O O O 8 O S O U Lender's Address PERMIT FEE G I a 09,26-86 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 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE -50 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WgRKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N E O U S APPLICATION CE 875 L u or rebaffum 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). PolicyNo. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS FICertified copy is hereby furnished BUILDING I LOCALITY ADDRESS L 0 Certified copy is filed with the county building inspection LOCALITY _ NEAREST department. CROSS ST Date Applicant NEAREST I G UP TY E 1PROC S D BY CROSS ST. JDA QI C /I �� C NST f✓ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J (J COMPENSATION INSURANCE' DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND OCAL _ NOOF BLD 65. - NO. (CIRCLE) . (This section need not be completed If the work Involved TRACT 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. K�/I r I certify that in the performance of the work for which this o permit is Issued, I shall not employ any person in any manner OWNERLcutoi `, y so as to become subject to the Workers' Compensation Laws MAIL , OCCUPANC�,.GROU`P, , ti i� o ADDRESS15 '1" Y •`I 1 Date Applicant - 1„ TE NOTICE TO APPLICANT If, after making this Certificate of CITY •4 NOL _ 3 OCCUPANT LOA'D N Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth A PLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION occurAN CY INSPECTION 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. PARKING SPACES REq'D D PROVIDED License Number Lic. Class • 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 NO. of FROM. TO INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code) FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING o a HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS tt,° •9 U ON LOT AND USE II $$Q I hereby affirm that I am exempt from the Contractor's d ° ° License Law for the following reason (Section 7031.5, Busi- 1 QTS 9:4--8 8 ness and Professions Code) NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED structure Is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE OF BUILDINGp� .-� CONSTRUCTION LENDING AGENCY �10�9.� 4•A I hereby affu-in that there is a construction lending agency ;�;- `�� `. ``' }. o ° for the performance of the work for which this permit Is - °' IssuedSec. 3097,Civ.Q. Lenders Names PROPOSED MAX OCC '(( O. ��8 8" 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 ordinances and State laws relating to building construction, and here authorize representatives of this County to enter TOTAL FEE upon the ove-menti property for Inspection yurppses. SEE REVERSE FOR EXPLANATORY LANGUAGE UfA i0/111"N12 Ignature of Permittee b ate