HomeMy Public PortalAbout4861 ARDSLEY DR_Miscellaneous_1987/01/12 WORKERS'COMPENSATI76M444 cC�LL!"iltlEOtJS APPLICATION
CE 875 (11-84) � I�J
I hereby affirm that I have a certiti.: consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compe;isation Insurance,or
a certified'copy thereof(Sec. 3800,Lab.C.).
Policy No. Company_
FOR APPLICANT TO FILL IN BUILOiNG -
ADDRESS
Certifiedcopy is hereby furnished. BUILD �G,/ �. LOCALITY '
ADDRESS
❑ Certified copy is filed-with the"'county building inspection LOCALITY /A" NEkREsr
department: - ,'�� CROSS ST.', .
Date Applicant 1 NEAREST / - 'DISTRICAT 1•yb. GR UP TYPE PR OC SSED BY
'- CROSS ST. L trier - CONST
,CERTIFICATE OF EXEMPTION FROM WORKERS' LEGA
J �V/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAF HIGH AY
• - ST.. .ATE,MAJOR
5 C
NO. OF BLDGS.
e
No. (CIRCLE) OND LOCAL
(This section need'not be 'completed if the work' involved TRACT NOW ON LOT .USE ZONEISPECIAL CONDITIONS - •
by the permit is for one hundred dollars ($100) or less.) 'USE: OF
SIZE OF LOT S �� -' '�
r EXISTING BLD�. LI O_
I certify that in the performance of the work'for which this o
permit is issued, I shall not employ`any person m any manner OWNER. g ;
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
• AD DR ESSMAIL Y ai. � O
Date Applicant _.. .
NOTICE T04 EPL
APPLICANT: If'after making this Certificate of CITY CA ` ,No.' ���.��' OCCUPANT LOAD
Exemption,' you should become subject •to' the';Workers'
_
Compensation provisions of the Labor Code, you must forth- AP LIGATION FOR.., EXIT HARDWARE:
with comply -with such provisions or this permit shk be TRAILER USE GEOLOGY INSPECTION - .❑
deemed revoked. ❑ ❑ No Spec. Know,.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION' Panic Devices
I,hereby affirm that I am licensed under provisions of Chapter SAFETYPeeMIT ❑: (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 ((�� C
effect. .:.. YR' /`o /YC Qv / -� I PARKING �I
SPACES REO'D PROVIDED 1'
License Number Lic. Class LIMITED TIME USE JJ
'Contractor. Date DATE - DATE
I am exempt from the licensing requirements as:I am a FROM: To:
licensed architect or a registered professional engineer slzE,oF- No. op INSPE TOR's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. - - • .STORIES
SIG ATURE
iness and Professions Code). FINAL APPROVAL. i
PRESENT USE OF BUILDING
Lic.or Reg.No. Date u
HOME OWNER-BUILDER DECLARATION NO.'OF EXISTING BUILDINGS 8 0.5 0
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 810. 5 O
ness and Professions Code): No. PARKING,
SPACES PROVIDED ' - S
�–—, as owner of the property, will do the work and the ? 8 7
structdre: is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE.OF BUILDING." r" •
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.Q.
Lender's Name,
PROPOSED MAX. OCC:
Lender's Address a
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
ordinances and State laws relating to building construction,
,and hereby authorize representatives of this County to enter TOTAL. FEE +;
upon 5e'ab ve-me oned'property-for inspection purposes.
SEE REVERSE.FOR EXPLANATORY LANGUAGE;.',.
(% Signature of Permittee Daie ,