HomeMy Public PortalAbout4933 ARDEN DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N
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I hereby affirm that I have a certificate CE 875 (11-84)of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION `llull
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800',Lab.C.).`
Polis No.—Company BUILDING i H �3 ,I �� r
Y P Y FOR APPLICANT TO FILL IN ADDRESS "r� (/I
El Certified copy is hereby furnished. BUILDING �J dl / I.C.
CA q1�C� 'r�rn V9 I e�
ADDRESS J 1s01. C. /c7V LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST. ,R ,:G{_ 5-�-
Date Applicant NEAREST y� p� ` DISTRICT NO. GROUP TYPE PR CESSED BY
CROSS ST. L,ow e/ 6 wsµ CONST/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 3
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. F BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) SIZE OF LOT 2 0 JUSOF
BLDG. >n:
OF
I
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 OWNER C14Ao014 C N y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS -O.
D�il
Date Applicant ^ w
os e rEL' ��Z��—�j�L� OCCUPANT LOAD
NOTICE TO APPLICANT: If, after makingthis Certificate of clrY K No. o N
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
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT E] (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. / J PARKING
&-W11/1 REQ D I PROVIDED
,. SPACES J
License Number Lie. Class / C' LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
Lie.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE s
I hereby affirm that I am exempt from the Contractor's t_ b
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING =`')•1' -°+�_''-I
I, as owner of theproperty, will do the work and the SPACES PROVIDED ;..
.E Z `i �� •
structure is not intended or offered for sale (Section
7044,Business and Professions Code). _I€H;_ _
PROPOSED USE OF BUILDING � ; �"�:? ate' '-
CONSTRUCTION LENDING AGENCY - _.. ._. ..
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 ti=I'?
PROPOSED MAX. OCC. -, -
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 757
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE _
upon the bove-mentigped property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig t e of Permittee Date