HomeMy Public PortalAbout5121 GOLDEN WEST AVE_Miscellaneous__ woiilMRs'COMPENSATION DECLARATION CE 875`(11-84) MISCELLANEOUS APPLICATION
I herebyaffirm
=N
I have a cartificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
fnsnre or aertlfica of Workers'Compensation Insurance,or
a cert�fled copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN ■UIIJDING
ADDRa/e
Certified copy is hereby furnished. ■ulLDlna J�/�� C 7 A EYE
F /
ADD.... 1I pis yC'/y W`S/ ,4YL, &YpLC C/T LOCALITY
Certified copy Is tiled with the county building inspection LOCALITY NaARaer �V/
department. CR Of/ fT.
Date Applicant NEAREST nD DIfT ICT N OUP Pa P C ft ■Y
CROSS ST. A R�Sg ✓" �-3 CONST.
CERTIFICATE OF E}�ITON FROM WORKERS' LaawL
COMPENSATION INSURANCE DafCRIPTION LOT NO. f LOCK YAC HMKWAY
Mo, (Cmc") /T
ATE: MAJOR SECOND LOCAL
/��{,�� [ NO. OF ■LDC■.
�a�u. section need not b0 C0lnpleted it file work 1nVOiVed TRACT 5Q N07 ON LOT .Z. U/a ZO Na ■Pa C-L CON!
ION■
by,,.tthy{e4'permit Is for one hundred doll. ($100) or less) //v u/a or J I
I wafuJ that In the perf0 ance of the work for which this� SIZE Or LOT D EXISTING fILD6.
�ra11 1a A4)-TiA)O SDo & JO-iE Sao
permit is issued, I not employ any person in any manner o>.NaR f� y
so as to become subject to the workers' Compensation Laws. / J /� y� r O CQPANCY GRO(Jlt [gal
PAIL SI DI Y W,/� /��G. "'..`y � �'.'I,`�'.
MAIL I
Date Applicant ,�y/QLO
NOTICE TO APPLICANT: If, after making this Certificate of CITY rEMr« cl rr NOL
. �p M) OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must fortis APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER Ula Gao LOGY INSPECTION
��revoked. ❑ ❑ No Spec. Knowl. El
Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INsracTlDN
I hereby affirm that I am licensed under provisions of C[lapter
9 (commencing with Section 7000) of D on 3 of the Buss /wraTY Pa.Yrc E] (Liar ITEMS ■aLor)
NO. OF aJ[rc■
nese and Professions Code,and my license is in full force and
effectfpc PAACES RKING Ra Q,r) pROVID aD
■
Liicariw Number Lie. Cbm l ( LIMITED TIME USE
Contractor Date DAT■ DAT/
F.Owl Tol
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered profbssional engineer s,Za or, No. Or IN/Pa CTOR•■
acting In my professional capacity (Section 7051, Bur KXIRTING ML-130. SVORla■ ■IG 'kTVRa
Ineuand ProfeadonsCode). FINAL APPROVAL 7i1
PR a1aNT Ula Or BUILDING
Lic,or Reg.No. Date
HOME OWNER BUILDER DECLARATION NO. OF azllTlnG 1UILDING■ 30
_ I
ON LOT AND USX
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031-5, Bush _ M —80.50
nets and Professions Code): NO. PARKING
® I, as owner of the property, wBl do the work and the ■Feces PRovlDao 1 ITS * ,
structure Is not intended or offered for sale (Section �;`+� _
7044,Businew and Professions Code). T 'y�[}�
PROPOSED Uea OF BUILDING •�'~ _ � .. '� .50
CONSTRUCTION LENDING AGENCY �yy
I hereby affirm that there is a construction lending agency Ll�'rL .. t;,.[ [�' ■UV
for the performance of the work for which this permit is _
issued(Sec. 3097,Civ.C.). -- -
Lender's Name DODO-OO1 7/19/89
PR OPO■aD MAX. OCC.
Lender's Address 4557 1 All 8'-59
PHRMIT FINE O
I certify that I have read this application and state that the
above information is correct I agree to comply with all County ISSUANCE FSE 01
ordinances and State laws relating to building construction,
and hereby authort7,e representatives of this County to enter TOTAL FEE
upon abo entioned property for inspection purpoea
7—
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa �of�Permittee Date