HomeMy Public PortalAbout5339 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
It, CE 875 (2-80)It, APPLICATION {�
I hereby affirm that I have a certificate of consent to self 'COUNTY„OF LOS ANGELES BUILDING AND SAFETY DIVISION �J
Insure', or a certificate of Workers'Compensation Insurance,or ,
a certified copy thereof(Sec 3800,Lab -C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING e{3
❑ _
\` ADDRESS L!
Certified copy is hereby furnished BUILDING LOCALITY
♦ ADDRESS64
Certified copy is filed with the county building Inspection NEAREST
LOCALITY Temple Cit -
department p y CROSS ST
Date Applicant NEAREST DISTRICT NO. 2UP ITYPEPRO ED BY
CROSS ST. Olive O CONST
CERTIFICATE'OF,EXEMPTION'FROM WORKERS' LEGAL - L
COMPENSATION INSURANCE DESCRIPTION I LOT No BLOCK Mpp /JI//��/ HIGHWAY }
(1J✓/ (CIRCLE) STATE MAJOR SEC D,LOCAL a
NO OF SLOGS IO
(This section need not be completed if the Work involved TRACT NOW ON LOT 1 Us ZONE SPECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.)
USE OF / I - -
cc
- _ _
I certify that m the performance of the workSIZE OF LOT EXISTING BLDG for which this �
permit is Issued, I shall not employ any person In any manner OWNER Alice Barrow Reid U
so as to become subject to the Workers' Compensation Lawg MAIL OCCUPANCY GROUP', 3 LU
ADDRESS 5339 Goldenwest FR N
Date Applicant-- Z
NOTICE TO APPLICANT'If,after making this Certificate of CITY Temple Cit No 285—2707 OCCUPANT LOAD ,
Exemption'„•you should become subject to. the WorkersAPPLICATION FOR EXIT HARDWARE
Com pen sat ion''provisions of the Labor Code, you must forth-
with comply With such provisions or this permit shall be TRAILER USE • ' GEOLOGY'INSPECTION No Spec. KnowL Eldeemed revoked Panic D
LICENSED CONTRACTORS DECLARATION occuPArlcY INSPECTION PeVIC@S
❑ V
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 Redwood Decx k 10 ' 16 ' PARKING.
effect SPACES REq'D - PROVIDED D
License Number Lic Class Cover 7 ' X 12 ' LIMIT ED_TIME USE O
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
_ FROM TO
'registered
licensed archdect or a registered professional engineer SIZE OF _ NO. OF
acting in my ,professional capacity.(Section 7051, Bus- EXISTING BLDG. STORIES _ S NATURE
mess and Professions Code) ' ' PRESENT USE OF BUILDING' - FINAL APPROVAL `� Q
Lic or Reg No Date- ail
STING
HOME OWNER-BUILDER DECLARATION, ON LOT ANNO OF'EXID USE USE BUILDINGS
�
I hereby'affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi- 4 7,7.NO PARKING '7 A
ness and Professions Code) SPACES PROVIDED #i•`•I• • 3 0
1, as owner of the property, will•do the work-and the r
structure Is not Intended or offered for sale (Section I • • (15,0
�
7044, BUslness'and Professions Code) PROPOSED USE OF BUILDING ` \1^`"
CONSTRUCTION LENDING AGENCY 8 Q 5 WE
I hereby affirm that there is a construction lending agency
for the performance of the work for which-this permit is 0 6,_0-5,.i7 i 8 6
Issued (Sec. 3097,Civ C)
Lender's Name PROPOSED MAX OCC.
Lender's Address PERMIT FEE 70 ^
I certify that I'zhave read this application and state that the V
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and liereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentione roperty,for inspectio I p •poses: SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of.Permittee I Datle