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HomeMy Public PortalAbout5028 ARDEN DR_Miscellaneous__ WORKERS' COMPENSATION DECLARATION 76M444MISCELLANEOUS APPLICATION 20-0063DPW 12/90 06 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,or,a certifiCa'te of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) _' Policy No. Company FOR APPLICANT TO FILL INBUILDING• A�ff //l BUILDING ADDRES Agk..bsV_, ❑ Certified copy is hereby furnished. LOCALITY ❑ Certified copy is filed with the county building inspection CITY ZIP GGG department. �/ NEAREST CROSS ST. Date Applicant SIZE OF LOT .OF BLDGS.NOW ON LOT DISTRICT NO.TRACT BLOCK LOT NO. GROUP TYPE / PJ�CE SSED BY OF EXEMPTION.FROM WORKERS' CONST. / G HIGHWAY COMPENSATION INSURANCE NO. (CIRCLE) STATE,MAJOR SECOND LOCAL,. (This section need not be completed if the work involved ASSESSOR PAG PARCEL USE ZONE SPECIAL CONDITIONS o by the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this OWNER t l f TEL NO. O permit is issued, I shall not employ any person in any manner �S (�(� so as to become subject to the Workers' Compensation Laws. nDMss OCCUPANCY GROUP Date Applicant Y r _ ZIP NOTICE TO APPLICANT: If, after making'this Certificater OCCUPANT LOAD Z of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forthwith comply with such provisions Or this permit,shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. No Spec.Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Devices N©� ❑ 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 Business NO.OF EXITS and Professions Code,and my License is in full'force and effect. �G' �!/L.� PARKING: REQ'D D PROVIDED D License Number Lic.-Class I ��O SPACES Contractor Date LIMITED TIME USE .. - DATE DATE ❑ 1 am exempt ,from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer ,acting in my professional capacity (Section 7051, Business SIZE N STORI INSPECTOR'SNATRS and Professions Code). EXISTING BLDG. STORIES PRESENT USF BUILDING FINAL APPROVAL } Lic. or Reg. No. Date Gee--����� 1 HOME OWNER-BUILDER DECLARATION NO.OF'EXISTING BUILDINGS ON LOT AND USE . �- - I hereby affirm that I am exempt from the Contractor's License ACCT•L Law for the following reason (Section 7031.5, Business and 242.70 Profossions Code): NO.PARKING M 1, as owner of the property, will do the work and the SPACES PROVIDED y 1 ITEMS structure is not intended or offered for sale(Section 7044, PROPOSED US F BUILDING TOTAL242 �� Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 242°70 I hereby affirm that there is a construction lending agency for CHANGE 00 the performance of the work for which this permit is issued (Sec. 3097. Civ. C.). PROPOSED MAX.OCC. - - - Lender's Name APPLICANT(PRINT) TEL NO. - 0000-0001 1/11/96 Lender's Address ADDRESS 4217 1 AM 9:29 1 certify that I have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE ✓d the above-mentioned property for inspection purposes. �/ TOTAL FEE ^� - /n SEE REVERSE FOR EXPLANATORY LANGUAGE Si azure of Permittee Date