HomeMy Public PortalAbout5007 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 78M444 MISC,�LLANE�US APPLICATION {�
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I hereby affIrm
cert that I have a certificate of consent tself CE 876 (11-84)COUNTY OF LO�ANOELES BUILDING AND SAFETY DIVISION
house, or a certificate of Wodcers'Compensation Insurance,
e,or
a cerdW copy thereof(Sea 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN ■DIED INS �Dv L
ADDRG/■ /
Certified copy is hereby furnished. ■u,LnlNo 0 L LO CA1-MY
Cerfflad wDDR[f/ ,{
department PY b filed with the county buflding inspection LOCALITY / /T NEAREST
{..�� CRO■S ST.
Date Applicant N[ARKST DISTRICT NO. 6 OUT TYPE C[■■[D ■Y
CROSS ■T. A-aaJ COX/T.
CERTIFICATE OF E}C1 MPTZS ' D _ON FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. �� I■LOCK MAP Mw MWAY
NO. F SEDC■.
NO. (CIRCI ) ■T
�7+{,r AT[ MAJOR SECOND LOCAL
/ ��
(aurection need not be COmp feted If the work Involved TRACT Z HOWOOX LOT USK ZONE SPE CU1L CONDITION/
by the permit is for one handred dollar (5100) or len.) X u■E of
SIZE OF LOT uXIf71X6 ■16o I LD6. 2-
I certify that In the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER
lo as to become subject to the Workers',Compensation Laws. PAIL O OCCUPANCY GROUP 3 CD
ADDRESS
Date- PP
NOTICE TO APPLICANT: If, after making this Certificate of CITY�Qw e C{ H0. F- OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compenaation provisions of the Labor Code,you must forth- AP ICATION FOR EXIT HARDWARE:1/
with comply with such provbions or this Permit shall be TRAILER USE E] GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked. i
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Sectlon 7000) of Division 3 of the Buz! Rwr[rY PERMIT ❑ (LIST rt[Y■ ■[LOW)
NO. OF EXITS
nen and Professions Code, and my license is in ftiIl force and
6N SPACES RKQ PROVIDED
License Number Lia Clans LIMITED TIME USE
Contractor Date DAT/ DAs/
PwDMI TOI
I am exempt from the Licensing requirements as I am a
Llconsed LrCbitect oI a registered profbisional engineer SIZE OF `� I jy NO. OF IX IGN TORE
acting in my professional capacity (Section 7051, But EXISTING ■LDG. ` r1 /T STORIES
SIGNATURE
mess and Profesaions Code).
PRESENT US[ OF BUILDING I FINAL APPROVAL F`/�
Lac.or Rog.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXI■71NG BUILDING■a M2 234.401
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 1 ITEM,
License Law for the following reason (Section 7031.5, Buri- r� 5
mss and Professions Code): NO. PARKING TOTAL I i �,
I SPACES PROVIDED Mcki 2,=4.45
as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
704 .i30
4,Business and Professions Code). � �
CONSTRUCTION LENDING AGENCY PROPOSED u■E of BUILDING SI`
I hereby affirm that there Is a construction lending agency 139*
for the performance of the work for which this permit is
blued(Seo. 3097,Civ.C.). 7621 1 PM 12%14
Lender's Name
PRoPosxD MAX. OCC.
Lender's Addrm
I-ca-tify that I have read this application and state that the PIERMIT Fla
above Information Is correct I agree to comply with all County ISSUANCK FKK
ordinances and State laws relating to buliding construction,
and hereby authorize representatives of this County to enter TOTAL F[¢
upon the abo red pro on p
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
tare of Permittee a