The URL can be used to link to this page

Home My Public Portal About5223 GOLDEN WEST AVE_Miscellaneous__ C. WORKERS'C htPENSATI ON DECLARATION CE8754(„ 84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab.C.). BUILDING Policy No Company FOR APPLICANT TO FI LL IN ^� ADDRESS Certified copy is hereby furnished. BUILDING yyZ? 0Z LOCALITY C• ADDRESS J 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST. Date Applicant NEAREST DISTRICT NO. GR UP TYPE PROCESSED BY ST. Sk CERTIFICATE OF•EXEMPTION FROM WORKERS' CROSSLEGAL �� coN COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SEC D LOCAL NO. OF BLDGS. (This section need not be completed if the work Involved TRACT NOW ON LOT USE ONE SPECIAL CONDITIONS by the permit Is for one huhdred dollars ($100) or less.) USE OF i SIZE OF LOT EXISTING BLDG. � I certify that in the performance of the work for which this o permit is Issued, I shall not employ any person in any manner OWNER y so as to become subject to tlie Workers' Compensation Laws. OCCUPANCY GROUP, %?j ce MAIL �•� A 1 p ADDRESS 6 (�'(J(iJ/♦� W� I � Date Applicant TEL. o. NOTICE TO APPLICANT• If, after making this Certificate of clrY C OCCUPANT LOAD No. �g�l�� C13Exemption, 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 TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter, SAFETY PERMIT ❑ LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and y� effect. l� PARKING REQ'D PROVIDED License Number Lic. Class D SPACES LIMITED TIME USE Contractor Date DATE DATE FROM TO I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR E acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES / sic ATURE mess and Professions Code). y� FINAL APPROVAL — PRESENT USE OF BUILDING ,` � Lic.or Reg No. Date o HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS G 8 7 a 2 A ON LOT AND USE I hereby affirm that I am exempt from the Contractor's — # o 0 0 • 30- License Law for the following reason (Section 7031 5, Busi- ness and Professions Code)• NO. PARKING '.•I e 980.50 ElI, as owner of the property, well do the work and the SPACES PROVIDED _ structure is not intended or offered for sale (Section ` •,O 0'8 Q 5 0 5: 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1.4 8 8 ` . I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ C). 4 Lender's Name PERMIT FEE `WPROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE J upon the above-mentioned property for inspection purposes. �• �,,, , r� �i` 1�A � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee U/` 4 Date WORKERS'COMPENSATION DECLARATION' CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or 'fl a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING _` a ' ' ADDRESS J ❑ 'Certified copy is hereby furnished AopREss ��13a ��f�Q! �E:��V v /7 /� LOCALITY , L Ceparft d copy Is filed with the county budding inspection �1Q n .`� NEAREST • de ar'tment LOCALITY CL+ cRoss sr Date Applicant NEAREST _ DISTRICT 99 G UP TYPE PRnD BY CROSS ST. IgzaC 1, �� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL _ COMPENSATION INSURANCE DESCRIPTION LOT NO �/ BLOCK rvoP (cGR Le) STATE MAJOR SEC ND LOCAL d ��',n� NO-,OF BLDGS _ (This section need not be completed if,the work involved TRACT {I 'tNOW ON LOTUS ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) 'ISE OFSIZE OF LOT XISTING BLDG. O�C I certify that in the performance of the work for which this 9 T Q 1 permit is issued, I shall not employ any person in any manner OWNER 0,f A S xJ�1te VARE� so as to-become•subject to the Workers' Compensation Laws OCCUPANCY GROUPUJ MAIEU :1 Date Applicant ADDRESS lxz•3 Go&oe J G e,,F, ' 1/ a a N er making this Certificate of clrrT`oM�� NOL OCCUPANT LOAD NOTICE TO APPLICANT If, aftZz Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE Compensation provisions of,the Labor Code, you must forth- w1th ,comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION NO Spec. Knowl. ❑ deemed revoked LICENSED CONTRACTORS DECLARAT,ION_: OCcuPArlcv INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions'of'Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with.Section 7000) of Division 3 of the Busi- ness,and Professions Code, and my license is in full force and PARKING effect ' 1 SPACES REO'D PROVIDED License Number Lic Class I � ia �0A) 06 I LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements•as I am a FROM TO licensed•architect or a registered professional engineer SIZCOF NO OF INSPECTOR'S acting In my professional capacity (Section-:7051, Bus- EXISTING BL STORIES S NATURE mess and Professions Code). PRESENT USE o uILDING FINAL APPROVAL Lic or Reg No Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUIL NGS ON LOT AND USE I hereby affirm that I am exempt from the'Contractor's License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING SPACES PROVIDED I, as owner-of the'property, will do the work and the h p structure is not intended or offered for sale (Section ' �{ 2,6 7 q 5'A 7044, Business and Professions Code) pR()POSED USE OF BUILDING #10 • •"• 3 0 of CONSTRUCTION LENDING AGENCY �,• • 8 a 5 0 I hereby affirm that there is a construction lending agency a for the performance of the work for which this permit -is • • - 80,5 0,5 04,02L Issued (Sec 3097,Civ C 87) ' Lender's Name` PROPOSED MAX occ. , Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and he by authon repres atives of this County to enter upo e above- r coned n erty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ' Sigi Lu�OFeittee Date COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS MCROFILM INFORMATION Record Search Building Address t Tract No. Lot No. Lot Size Building Permit Issue Date Final Date Description of work Sq. Ft. Building Permit # Issue Date Final Date Description of work Sq. Ft.____—_�_ Building Permit # Issue Date Final Date Description of work Sq. Ft. Building Permit # Issue Date Final Date Description of work Sq. Ft._;_ Building t. - Building Permit ; issue Date Final Date Description of work Sg. Ft Note: The information given is ,taken from Building Permit Records. Unless an Occupancy Inspection is requested and the fee for this inspection is paid, no investigation of the property will be made by this Department. Sewer Permit # Issue Date Connected to sewer in street : Inspection Date enior Clerk