HomeMy Public PortalAbout6472 LIVIA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have certificate of consent nc 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 FOR APPLICANT TO FILL IN BUILDING _
ADDRESS
❑ Certified copy Is hereby furnished BUILDING / �' 1 1 J ` tj LOCALITY I
ADDRESS (p L
❑ Certified copy is filed with the county building inspection NEAREST
department LocALIrY '�mPL� Cp 1 R CROSS sT
Date Applicant NEAREST DISTRIC J^O GRO TYPE PROCESSED BY
CROSS ST �M `j�0 CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOAp HIGHWAY
is 5o NO OF BLDGS (CIRCLE) STATE MAJOR SECOND LOCAL a
(This, section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) _ U
USE OF
SIZE OF LOT07C/ EXISTING BLDG.
I certify that in the performance of the work for which thi
permit Is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws MAILOCCUPANCY GROUP W
Date Applicant ADDRESS
S Cn
TEL.
NOTICE TO APPLICANT If, after making this Certificate oo�� cirr ��( � NO. 6_1 —17.1-Z 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 ❑
deemed-revoked EEI No Spec. Knowl ❑ '
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 'Panic D2VICe5
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (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 PARKING
effect SPACES REQ'D D PROVIDED D
/O
License Number Lic Class
LIMITE'D TIME USE
L�� FROM ontractor Date DATE DATE
`F❑ TO
I am exempt from the licensing requirements as I am a
INSPECT 5
- licensed •architect or 'a registered professional engineer sizE of No of �,i°
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES ! 1 NATU E+
iness and Professions Code) PRESENT USE OF'BUILDING FIN'ALr PR0VAL
CJ`
LIc or Reg No Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
• ON LOT AND USE
I he affirm 2321-A
m that I am exempt from the Contractor's ,
License Law for the following reason,(Section 7031 5, Busi- #'� �;O 0 ,3 Q
ness and Professions Code) NO PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the ` 2 •8(�5 Q
structure is not intended or offered for sale (Section '
7044, Business and Professions Code). o o e 8 T5 Q=
PROPOSED USE OF BUILDING , I ,U
CONSTRUCTION LENDING AGENCY 05,31,-8 3
I hereby affirm that there is a construction lending agency
for the performanceof the work for which this permit is
issued(Sec 3097,Civ •C)
Lender's Name PROPOSED MAX. OCC ,
Lender's Address PERMIT FEE - c�l- a
I certify that I have read this application and state that the - s�,
above information is correct i agree to comply with all County ISSUANCE FEE v� .
ordi nces and State laws relating fo building construction, TOTAL FEE S�
an h reby authorize representatives of this County to enter
n the ove-mentioned•property for Inspect n p rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
I Z"3l 3
Si tore of P r tt a '��� Date