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HomeMy Public PortalAbout4847 GOLDEN WEST AVE_Miscellaneous__ n vVORIcER-iCOjvIPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent self COU OF L S ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or i a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company ka-APPLICA4dTO FILL IN BUILDING ,yam ❑ Certified co ADDRESS Y' copy is hereby furnished. BUILDING �/1 r U)E7SF v LOCALITY ❑ - ADDRESS /d J 4 Certified copy is filed with the county building inspection �, p NEAREST department. LOCALITY �/ CROSS ST. t Date Applicant NEAREST DI TRI T O. G U� T PE P C SSED BY CROSS ST. o /c� I�1�/J� /y ONST./ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL VVV COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SE ND LOCAL (This section need not be completed if the work involved TRACT NOW ON LOT S USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) 0 USE OF �Sr �1 I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG. I permit is issued, I shall not employ any person in any manner OWNERJ so as to become subject to the Workers' Compensation Laws. MAIL ,` OCCUPANCY GROUP LLJ' Date Applicant ADDRESS 14S 6,oa f©pu �, VG_ Ave:- NOTICE TO APPLICANT: If, after making this Certificate of CITY ® �'� C�� NO- ����� - ���/ OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this -permit shall be TRAILER USE E] GEOLOGY INSPECTION ❑ deemed revoked. ❑ 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) NO. OF EXITS ❑ 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and �.72 L /�� �� PARKING. effect. �V SPACES REQ'D PROVIDED License Number Lic.Class L� .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 /) �'�''' P NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bos- EXISTING BLDG. I Y®�j�.�"���d�'//' STORIES SIGNATURE mess and Professions Code). PRESENT USE OF BUILDING 1� FINAL APPROVAL Lic.or Reg.No. Date G 1 L 1 NO. OF EXISTING BUILDINGS # 0 ® 0 0 3rl HOME OWNER-BUILDER DECLARATION ON LOT AND USE _ V I hereby affirm that, I am exempt from the Contractor's I' e ® 80,50 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ° ° - 80.500 SPACES PROVIDED r' ❑ I, as owner of the property, will do the work and the 2 8 structure is not intended or offered for sale (Section vv � 7044, Business and Professions Code). Q PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 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. 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, TOTAL FEE and hereby authorize representatives of this County to enter up v entioned property for i eCtio�purpos .. SEE REVERSE FOR EXPLANATORY LANGUAGE 9-lea t u fe of P rmittee Date