HomeMy Public PortalAbout4929 GOLDEN WEST AVE_Miscellaneous__ wo"s'COMPENSATION DECLARATION
CE 87.6 (11-a4) MISCELLANEOUS APPLICATION
3 CE 87
I hereby affirm that I have a certificate of consent to mlf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insvm, or a artiflate of Workers'Compensation Insurance,or ,r
a cartifled copy thereof(Sea 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FI LL IN ■UILn IN6 a
AD DR if■
Certified copy is hereby furnished_ ■uILDING �• —
AD DRi■■ LOCALITY
DCertified copy Is Mad wity,th the county building inspection LOCALITY C CROS ST
department cwo/■ n.
Date Applicant HKARR/T DI/TRIC NO, GROUF TYri PROC[//iD ■Y
CROSS ■T. �� - CONST. ,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LK AL �/
COMPENSATION INSURANCE D[/CRIPTioH LOT NO. ■LOCK �� HM.r�AY
.0. (C RCLi) /TATs MAJOR ■i COHb LOCAL
NO. Or IS L13 G■.
(ThisU/i ZONE ■PiCUL CON.ITIONf
\++� section need not be C�7npl0ted a work involved TRACT HOW OH LOT
by the permit is for one hundred dollars ($100) or len.)
u/i or
/IZi OF LOT izI■TING ■LDG.
I certify that fn the performance of the workfor which this
permit is issued, I shall not employ any person in any mannas OWNiR L�/ 0
vdow s.')
so as to become subject to the Workeas Compensation Laws ?
MAIL OCCUPANCY GROUP `J o
Date Applicant TXL AD DRi// W
NOTICE TO APPLICANT: If, after making this Cortlficaxe of CITY NO. 7� 3 OCCUPANT LOAD N
Exemption, you should become subject to the Workers z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be E] No Spec. Knowl.
deemed revoked. TR AILiR U■i GiO LO GY IH■Pt CTION
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN■PKCTION A Panic Devices E]
I hereby aft that I am licenced under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Susi SAFETY PiR Mrr ❑ (LIST ITiM■ ■iLOW)
NO. OF iz[T■
ness and Professions Code,and my license is in fhII force and
effect. ■PACiG Riq'D ...".13
License Number Lia Clan
ZyiP � LIMITED TIME USE
Contractor Date DAT/
DAT=
I am exempt from the licensing requirements as I am a 'Roma Toy
licensed architect or a rogiatered profbudoml engineer ■IZi or No. or IN/r[cTO R'■
acting in my professional capacity (Section 7051, Bus- izl■71X6 ■LD O. ■TORR■ RIG Tuns
inenand Professions Codie)
. ;� FINAL APPROVAL IM—gIz-
Lic,or Reg.No. Date rRi■iNT Uli Or ■UILDING
,5'1116 C
HOME OWNER-BUILDER DECLARATION Ho. Or [KITTING BUILDINGS
ON LOT AND U■i
Hti�• .
I hereby of irm that I am exempt from the Contractor's /+� I r
License Law for the following reason (Section 70315, Bull- .71
nets and Professions Code): No. PARKING
I, as owner of the property, will do the work and the ■Pwcie PROVID[D
structure is not intended or offered for tale (Section }
7044,Business and Professions Code). I YI f. 219 - 75
T
CONSTRUCTION LENDING AGENCY PROPO■KD U/i Or BUILDING f F.�. 11S.
I hereby affirm that there is a construction lending agency �yf�' L
for the performance of the work for which this permit Is
Issued(Sea 3097,Civ.C.).
Lender's Name Til l—C 11 10/ 6/
r,
rROPO■LD MAX. OCC.
Lendees
certify thahave read this application and state that the PERMIT P[Q Ori X41 1 f 11ia.41
above information Is correct I agree to comply with all County 155UANCK Fa EI
ordinance and State laws ting to baildg construction,
and by anthorke b twos of this bounty to enter TOTAL F[H a 9
u o above-menti perry for inspection purposes.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
S of Permittee . Da