HomeMy Public PortalAbout4850 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I`hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec.3800,Lab.Q.
BUILDING
Policy No. Company FOR APPLICANT TO FI LL IN ADDRESS
Certified copy is hereby furnished. BUILDING g�0 f LOCALITY
ADDRESS
DCertified copy is filed with the county building inspection LOCALITY ^ NEAREST 7
department. rL CROSS sT. Z—D (ice
Date Applicant NEAREST DISTRICT NO. I GROUP TYPE PROCESSED BY
CROSS ST. V U CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NONO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO,
.OF
section need not be completed if the work involved TRACT NO ON
BLDGS.ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF y!�
SIZE OF LOT EXISTING BLDG. /l
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 Ti! K ftllcf, 7TCD 1,J Q7 y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
Date Applicant / `)c ,/, 'A � ADDRESS U
_� `
NOTICE-TO APPLICANT: If, after making this Certificat of CITY T rEL. OCCUPANT LOAD a
to
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth—
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
E] ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] 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. PARKING
License
PROVIDED
License Number SPACES Lic. Class //�� LIMITED TIME USE
Contractor Date I DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF No. OF INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL
Lic.
USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
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- 8 0 4.8 A
ness and Professions Code): NO. PARKING
F] I, as owner of the property, will do the work and the SPACES PROVIDED # • • • • 30
structure is not intended or offered for sale (Section I • * 80,50
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING • • • 8 0 5 0
I hereby affirm that there is a construction lending agency 1 0.05-87
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
I certify that I have read this application and state that the PERMIT FEE Qo
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 the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date