HomeMy Public PortalAbout5306 ARDEN DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm'certificate of
have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificicate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APP LICANTTO FILL IN BUILDING
ADDRESS ✓ to
Certified copy is hereby furnished. BUILDING y
ADDRESS (y /V t I LOCALITY
Certified copy is filed with the county building inspection LOCALITYNEAREST
�- r/G
department. � /M /`� L f CROSS ST.
Date Applicant NEAREST DISTRICT NO. G OUP TYPE P 11 1E BY
CROSS ST. P E p / rJ -� CONST. 1/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Cy�l VA j/
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.) USE OF
SIZE OF LOT EXISTING BLDG.
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
so as to become subject to the Workers' Compensation Laws. MAIL ,` { OCCUPANCY GROUP y� 3 0
Date Applicant ADDRESS - ` /VG , y '
TEL' `J OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY C NO. HyL/.- Z7 7 7
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
deemed Ievoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
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 Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. 9
PARKING REQ'D O PROVIDED D
SPACES
License Number Lic. Class
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 INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVA J_�
PRESENT USE OF BUILDING j
Lic.or Reg.No. Date, e i�l
r. ^
HOME OWNER-BUILDER"DECLARATION NO. OF EXISTING BUILDINGS y +r
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 -!.V!,
ness and Professions Code): NO. PARKING - -••=
I, as owner of theproperty, will do the work and the SPACES PROVIDED r - ^=
4{ $
structure is not intended or offered for sale (Section _
7044,Business and Professions Code). f' _ '%}` ,•_ ._ '`:
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I ik:w�j 4
isrii
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
PROPOSED MAX. OCC. A Ix.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE c , 75—
ordinances
jordinances and State laws relating to building construction, /
and hereby authorize representatives of this County to enter TOTAL. FEE
upon t a ove-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date