HomeMy Public PortalAbout4909 GOLDEN WEST AVE_Miscellaneous__ WCOhPENSATION DECLARATION
CE 876 (1141 M ISCELLANEOUS APPLICATION
�� •. CE 876
I hereby affirm that I have a certificate of consent to self COUNTY OFLOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Woriceri Compensation Insuance,or
a cert�fied copy them(Sec 3800,Lab.CJ.
Policy No. Company FOR APPLICANT TO FILL IN OILDING
AD DR[//
Certf od copy is hereby furnished. ]BUILDING LOCALITY
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Cortifled copy Is filed with the county building InspectionLD-CALITY KXAI![/T
department. CRO/■ WT.
Date Applicant N[AR[fT DIRT L XILIA _ U TYr rROc[P93- or
CRO■/ ST.- Ute( CON
CERTIFCOICATE OF EXEMPTION FROM WORKERS' LXGAL MPENSATION INSURANCE D[/CR IPTION LOT NO. ■LOCI[ Ir.,
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CIwa Lam) /TAT[ YAJOR SKCOPaLOCAL
/��,�� NO. Or IN LID O/.
�aau� �OCtiOn need not b0 COfi'lppieted if the work involved TRACT NOl•OX LOT U/[ N[ 1P[ C IT
by the permit is for one hundred doilan (3100) or less) U/[ or
■II[ OF LOT [%IITING ■ O.
I arrttfy that in the performance of the work for which this
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perm-it is Issued,I stall not employ any person in any manner ONN[R 4 A ,
so as to become subject to the Workers' Compensation Laws. -MAIL OCCUPANCY GROUP o
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Date— PP �A U
NOTICE TO APPLICANT: If, after mak lag this Certificate of CITY ��1 Cj� r", ✓� OCCUPANT LOAD
Exemption, you should become subject to the Workers' --
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAIL[R U■[ ❑ G[o Y.INzr[crlon ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION occurwnaY IN/P[aT1oN Panic Devices
I hereby affirm that I am licensed under provisions ofChapter
9 (commencing with Section 7000) of Division 3 Of the gush 140.P[RYIT ❑ (LIST IT[Y■ ■[LOi)
NO. Or t7CIT/
mss and Professions Code,and my License is in full force and
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effect rn PARKING R[q•D PROVID[D
QAC[/
License Number Lia Clara .LIMITED TIME USE-
Contractor
SE "Contractor Date D AT L OATS
I am exempt from the Licensing requirements as I am a rRo�l TO.
licensed architect or a registered professional engineer ■a[ Or No. or In■ R•/
acting in my professional capacity (Section 7051, Bur <JCI/TING ■LD O. /TORI[■ ■IortAT NwTUR[
iness and Professions Code).
PR[/[NT Ul[ or ]BUILDING FINAL APPROVAL
Lia or Reg.No., Date
HOME OWNER�BUILDER DECLARATION No. Or [X9/TINO ]BUILDING/ 29421 A
ON LOT AND U/[
I hereby affirm that I am exempt from the Contractor's # 0 o / 0-30
License Law for the following reason (Section 7031.5, Bull-
mss and Professions Code): no. PARKING F -0 - 80.50
❑ I, as owner of the property, will do the work and the /PACKS PROVID[D
structure Is not Intended or offered for sale (Section / 0 0 8,0,5 0 ci
7044,Business and Professions Code).
rRoro/[Do4. 19-88
u/[ or 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(Sea 3097,Civ.C.).
Lender's Name
PROPO■[D MAX. OCC.
Lender's Address
PISRMIT FH[
I certify that I have read this application and state that the
above Information is Correct I agree to comply with all County ISISUANCK FISH .
ifzanav tate laws relating to bufldiag construction, z 0Q2
by th of this• ounty to enter TOTAL F[0.
th m do r inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date