HomeMy Public PortalAbout5414 GOLDEN WEST AVE_Miscellaneous__ ry WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I Hereby affirm that I hazie -.i certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certifiesate of Workers'Compensation Insurance,or 1, . -
"a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICNT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS19
❑ Certified copy is filed with the county building inspection
LOCALITY NEAREST
department; - � CROSS ST. '
Date Applicant NEAREST DISTRICT NO. G OUP TYPE PR SED BY
CROSS ST. JJ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATdON INSURANCE
DESCRIPTION LOT NO. / BLOCK MAP HIGHWAY STATE MAJOR SE OND LOCAL NO. OF BLDGS. NO. (CIRCLE) a
I n
(This section need 'not be completed if the work involved TRACT/ 2 NOW ON LOT USE ZONE rPECIAL CONDITIONS O
by the. permit 'is for one hundred dollars ($100) or less.) usE OF /
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this 1 0
permit is issued, I shall not employ any person in any manner OWNER U'
so as to become subject to the Workers' Compensation Laws. MAIL � OCCUPANCY GROUP J LL
.ADDRESS �J �OL �ll �^" CL
Date Applicant / Z
NOTICE TO APPLICANT: If, after making this Certificate of CITY r, a NoL '�20 OCCUPANT LOAD z
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 TRAILER USE GEOLOGY INSPECTION '
❑ No Spec. Knowl.
deemed revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 Q n 6 ROOM ) pU PARKING. �1
effect. v /CREO D I' PROVIDED
SPACES L_LL JJJ II��JJ
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: To:
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING L/
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE -
I hereby affirm that, I am exempt from the Contractor's ;2682 6 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING {{{{ •
SPACES PROVIDEDtt ,0 0.0 30
❑ 1, as owner of the property, will do the work and the
structure .is not intended or offered for sale (Section • - 80,5 0
7044, Business and Professions Code).
PROPOSED USE OF BUILDING - "O O • 8,0,5.0 U
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 0 I. 08-87
for the performance of the work for which this permit-is
issued (Sec. 3097,Civ.C.).
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 ot
to
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE to S
�•
upon the above-mentioned pro erfy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �J
Signature of Perm Date