HomeMy Public PortalAbout4953 ARDSLEY DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby af£ert that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or ,
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING ��
ADDRESS
75 Certified copy is hereby furnished. BUILDINGLOCALITY
-3 RQ S,
ADDRESS 5
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. C C T r -, CROSS ST.
Date Applicant NEARESTDISTRICT NO. GROUP TYPE I L.R.9CESSED BY
CROSS ST, CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
ND, (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT ` USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOTEXISTING 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 OWNER
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP a
ADDRESS zil
Date Applicant I LO
NOTICE TO APPLICANT: If, after making this Certificate of CITY Q e— NOL jZg 3 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICA ION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with Section 7000) Of Division 3 of the Busi- ❑ (LIST ITEMS BELOW) NO, OF EXITS
ness and Professions Code,and my license is in full force andp
effect. PARKING SPACES REQ'D D PROVIDED D
i
License Number Lie. Class ( I* LIMITED TIME USE
Contractor Date ' 0�\- 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 INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL
Lie.or Reg.g No. Date PRESENT USE OF BUILDING / /A
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS /
ON LOT AND USE ."•i•'•
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING _
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 1 '::L
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING - AA
I hereby affirm that there is a construction lending agencyri:ii'rt
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q. v
Lender's Name _ _
PROPOSED MAX. OCC. _'�al'��'•'�_'jl_-, 'yi_i,i
s.1
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,,
and hereby authorize rep sentatives of this County to enter TOTAL FEE S�
upon the above-mentio grope ty or inspection purposes.
i1 �?r 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
•t Sig re of Permittee Date