HomeMy Public PortalAbout5011 ARDEN DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) W SC E L LA N E O U S APPLICATION
I hereby:affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
'insure, or a certificate of Workers'Compensation Insurance,or 'fl
a certified copy thereof(Sec. 3800,Lab.C.)
an
BUILDING-
Policy Polic l`
Y No. Company-Y FOR APPLICANT TO FILL IN ADDRESS u1 /
❑ Certified copy is hereby furnished. BUILDRESING meq.J =N LOCALITY ;
AOLL
F-1Certifiedcopy is filed with the county building inspection `., NEAREST
department. LocwLlTr ] '�� cRoss sr. �C
Date Applicant NEARESTr— r DISTRICT NO. GR P TYPE J:!O�DY
CROSS ST. asr /l�� ' CONST./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/
DESCRIPTION LOT O
>_COMPENSATION INSURANCE N .. BLOCK MAP IGRwAr STATE MAJOR SECOND LOCAL
NO. (CIRCLE) O
(This section need not. be completed if the work involved NO. OF BLDGS.
p 'TRACT NOW ON LOT MST` SE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF i
.SIZE OF LOT EXIST NG BLDG.
I certify that in the performance of the work for which this � 0
permit is issued, I shall not employ any person in any manner owNER 6`s
so as to become subject to the Workers' Compensation Laws. MAIL ���/r �
OCCUPANCY GROUP W
ESS. // d
ADDR
N
Date Applicant r
NOTICE TO.APPLICANT: If, after making this Certificate of CITY / jr. NYT.�- -�. OCCUPANT LOAD 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 E] GEOLOGY INSPECTION
❑ No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices ❑
I hereby affirm that I am licensed un der,provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO, OF EXITS
❑
9 (commencing with Section 7000) of Division 3 of the BUST-
,ness and Professions Code, and my license is in full force and 'r
PARKING
effect. SPACES REQ'OE= PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a
licensed architect 'or a registered professional engineer 'SIZE OF No. OF INSPECTOR'S
acting in'my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
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
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED 2 6 7 7'4 A
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section #.° ® o 3
7044, Business and Professions Code).
PROPOSED USE OF BUILDING I o o80, 50
CONSTRUCTION LENDING AGENCY o.o o g Q 5 0
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.). 03.31 —87
Lender's Name PROPOSED MAX.'OCC.
Lender's Address_ PERMIT FEE I 0
I certify that I have read this application and state that the V
ISSUANCE FEE
above information is correct. I agree to comply with all County .J
ordinances and State laws relating o building construction, �-0
and hereby authorize representat' e of this County to enter TOTAL J \V
FEE
upon t above-mentioned o y for inspect' purposes. SEE REVERSE_FOR EXPLANATORY LANGUAGE U1��
_Qwture of Permittee Date