HomeMy Public PortalAbout4934 GOLDEN WEST AVE_Miscellaneous__ WORKERS'C66lPENSA7IONDECLARATION
CE 876(11-84) MISCELLANEOUS APPLICATION
CE 876
I hereby affiim that I have a certliicaYe of consent to selfCp COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Wo&ers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL INBUILDING
ADORESI
❑ Certified copy is hereby furnished. BUILDING
AD DR ES■ 4934 1W, olden West Ave. LocwLrrY
❑ Certified � 0 � inspection LOCAL .AR[/T
department. empey, a . RO// �y
R. f�
Data Applicant NEAR.ST DI■rRICT NO. 6�P U TYPE PR /. ■Y
CROSS ST. La Rosa Dr, to the north S /� OO NST.(/
CERTIFICATE OF EXEMPTTON FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIWHRAv
wo. (alR aLcj /TAT. MAJOR ■EC LOCAL
Q R NO. O . S
F BLDG■.
section need not be com feted if the work invol"d TRACT 1 9o8 NOW ON LOT 1 USE XONP.CIAL CONDITION&
by the permit Is for one hundred dolls ($100) or lals.) us
SIZE OF LOT 57► X 150' EXIEDToIfNG BLD G.Res I dent
I om-ffy that In the performance of the work for which this CD
permit is issued, I &hall not employ any person In any manner OWNER Ta kum i 0 i n o and Jean N. 0 i no S-'
&o as to become subject to the Wor3cerr{ Compensation haws MAIL OCCUPANCY GROUPEtZ a
00-1
ADDRESS 4934 N. Golden West Ave. t
Date Applicant LTJ
NOTICE TO APPLICANT: If, after makfn this Certificate of CITY Temp 1 e City No" (818) 285-6777 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 ❑ ❑ No Spec. Know[.
deemed revoked TRAILER Ul. GEOLOGY IN■P.CTIOn
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑,
I hereby eftIrm that I am licensed underprovisions of Chapter
9 (commenting with Section 7000) of Division 3 of the Busi- ■AF ETY PERMIT ❑ (LIST REL/ ■.LOBI ❑
NO. OF Exlr■
nen and Professions Code,and my License is In full force and
effect. t7' PARKING RKQ'D PROV mED
SPACES
Licence Number Lic. Clara ►0 t sJ G
LIMITED TIME USE
Contractor Date DATM DA r
❑ I am exempt from the licensing requirements as I am a PwDrl
TD.
licensed architect or a registere,}d�'profbsalonai engineer /IXE OF No. of INeP.croR'■
acting In my professional capacity (Section 7051, BIIF EXISTING BLDG. 21(Y'1' s ,ft. ---T1-1 OTC; IE■ 1 GNATURE
ima and Professions Code).
PRE/ENT USE OF BUILDING 1 fami I res Idence FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No. of EJCISTING BUILDING■
ON LOT AND U/E None other than
I hereby affirm that I am exempt from the Contractor's stated above
License Law for the following reason (Section 70315, Busi-
ness and Professions Code): No. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED None 6 5.L 6 A
structure Is not intended or offered for sato (Section # "'IS•/ 3 Q
7044,Business and Professions Code). C • • 8 Q 5 0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BuILD1NG Owner occupied 1
1 hereby affirm that' there is a construction lending agency family- residence 8Q50.6
for the performance of the work for which this permit is 02 1 3 s 8 7
blued(Sea 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OOC.
Lender's Address 7011" 1 .
I certify that I have read.this application and state that the PERMIT F[[
above Information if correct I agree to comply with all County 15SUANCK FEZ 1 _
ordinances and State laws relating to buff construction,
and hereby authorize representatives of this County to enter TOT,u FE[
upon the above-mentioned pro rtyffor impaction purposes
I SEE REVERSE FOR EXPLANATORY LANGUAGE
-/�-S 7
Signature of Permittee Date