HomeMy Public PortalAbout5037 ARDEN DR_Miscellaneous__ `WORKSRS'COMPENSATIONDECLARATION E 8 875 75 (11-84)
C
y CE MISCELLANEOUS APPLICATION JJ��
I hereby affirm 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.).
olicy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
`f v
Certified copy is hereby furnished. BUILDINGZJ'03-7w. en e,
ADDRESS / LOCALITY
ElCertified copy is filed with the county building inspection LOCALITYNEAREST
department. TCr9 0CC It CROSS ST.
Date Applicant NEAREST DISTRICT NO. G OUP TYPE PROCESSED BY
CROSS ST. �I CONST.
IV
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L3 �nsaU
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. F BLDG
NO. (CIRCLE) STATE MAJOR SE- ND LOCAL
(This section need not be completed if the work involved TRACT 3`) NOWOS.ON LOT USPI
SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF Lor EXISTING BLDG. o
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MESS AlAIL ,� L' ' �� OCCUPANCY GROUP o
DD
Date A
Applicant LLI
50
NOTICE TO APPLICANT: If, after making this Certificate ofcITY No �75'��� OCCUPANT LOAD 0-
Exemption, you should become subject to the Workers' APP KATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with comply with such provisions,dr this permit shall be
deemed revoked. TRAILER USE GEOLOGY INSPECTION No Spec. Knowl.
r Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code,and my license is in full force and ((ff��
effect. or 1. oc O n � ic) � PARKING REQ'D = pROVID ED
SPACES
License Number Lic. Class er
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 OFNO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. r X STORIES SIG ATURE
iness and Professions Code). R XQ (�oe5t' rl FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
F- a
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's L,[1
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING [{:`_I e4
SPACES PROVIDED -
I, as owner of the property, will do the work and the 337 -1 ;:;1;e•:��
structure is not intended or offered for sale (Section ! '�
7044,Business and Professions Code). ITEM
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING ITHL -,130 _ 50
I hereby affirm that there is a construction lending agency QCA Roo ri r: (I:L ,a)Ia5:i
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). {=� .iii
Lender's Name
PROPOSED MAX. OCC.
Lender's Address ,r,�.,T,
I certify that I have read this application and state that the PERMIT FEE ii ifl i-4!DO1 is12"1
above information is correct.I agree to comply with all County ISSUANCE FEE I_i6i t AN 10:L
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upo thea ove- nt ed property for inspection purposes.
t SEE REVERSE FOR EXPLANATORY LANGUAGE
23"89
Signature of Permit e Date