HomeMy Public PortalAbout4874 ARDSLEY DR_Miscellaneous__ WORKERS; COMPENSATION DECLARATION 20.0063DPW1.2/90 MISCELLANEOUS APPLICATION
I hereby affirm'that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a cert fiLjie of Workers; Compensation Insurance, or
a certified`copy thereof (Sec. 3800, Lab. C.) ��-
Policy No. Company' FOR APPLICANT TO FILL IN BUILDING
BUILDING ADORE d
ADDRESS O
❑ Certified copy is hereby furnished. LOCALITY
❑ Certified copy is filed with the county building inspection CITY , zip
department. ;7Cf' NEAREST,
CROSS ST.
Date Applicant SIZEQF,,6OTf V NO.OF BLDGS. WON LOT DISTRICT NO. G UP TYPE P ZiESSED BY
X/ / CONST. '
CERTIFICATE OF EXEMPTION FROM WORKERS' O
COMPENSATION INSURANCE TRACT S BLOCK LOT NO. �� MAP HIGHWAY V
NO. (CIRCLE) STATE MAJOR SECOND LOCAL.
(This section need not be completed if the work involved ASSESSOR MAP BOOK �y PAGE PARCEL USE ZONE SPECIAL CONDITIONS — -
by the permit is for one hundred dollars ($100) or less.) �'J�(� 0
I certify that in the. performance of the, work for which this OWNER p, TEL NO.
permit is issued, I shall not'employ any person in any mannerAP 5 IY.E�T p,
so as to become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP Y�—� Z
Date' Applicant CITY zIP
NOTICE TO APPLICANT: If, after'making this Certificate OCCUPANT LOAD
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❑
No Spec.Knowl. ❑
revoked.
OCCUPANCY INSPECTION❑ - -- Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
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 El
and Professions Code,and my license is in full force and effect.
PARKING• REQ'D D PROVIDED D
License Number Lic. Class sPAelas '
Contractor Date alm 44t- w LIMITED TIME USE
--- - - DATE DATE
F1 I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer
actin in m professional ca acit Section 7051. Business SIZE OF NO.OF INSPECTOR'S
g y p p' y ( EXISTING BLDG. STORIES SIGNATURE ,
and Professions Code).
Lic. or Reg. No. - Date PRESENT USE OF BUILDING FINAL APPROVAL
� !N
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 30
ON LOT AND USE /�L�/+�T.T
I hereby affirm that I am exempt from the Contractor's License FFtI
Law for the following reason (Section 7031.5, Business and 3303 242.70
Professions Code): NO.PARKING
❑ 1, as owner of the property, will do the work and the SPACES PROVIDED 1 ITEMS
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING TOTAL 242.70
Business and Professions Code). CHECK 242.70
CONSTRUCTION LENDING AGENCY
1 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 11/ 7195
Lender's Address ADDRESS 3203 1 FM 6.44
I certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County PERMIT FEEj L/U
ordinances and State laws relating to building construction,and ' 1 7 `
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes. �s30 -
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date