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HomeMy Public PortalAbout5477 GOLDEN WEST AVE_Miscellaneous__ Irla' ' • ' WORKE4 RS'COMPENSATION DECLARATION CE 8754(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent 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) Policy No Company FOR APPLICANT TO FILL IN BUILDING -77 ADDRESS ❑ Certified copy is hereby furnished BUILDING j— LOCALITY D ADDRESS`? _DHAI Certified copy is filed,with the county building mspectmn LOCALITY NEAREST A department f f �� CROSS ST Date Applicant NEAREST DISTRICT N G PIS TYPEPROC ED BY CROSS ST. , f�Q9DJ/dJ�T S �/ryl/ 3 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I Y COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY (CIRCLE) STATE MAJOR SECON LOCAL NO + •tL (This section need not be coin leted if the work involved No of BLDGs p P TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) I usXIESTINof LOT �© x EG BLD G. �p 0 I certify that in the peSIZE OF performance of the work for which this S, permit Is issued, I shall not employ any person in any manner OWNER D � so,as,to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP w ADDRESSZOwy d Date Applicant N TE Z NOTICE TO APPLICANT If, after making this Certificate'of CITY Q D No3 3 OCCUPANT LOAD Exemption, you should• become subject to the Workers' APPLICATION OR 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 Panic Devices ❑ LICENSED CONTRACTORS DECLARATION * OCCUPANCY INSPECTION 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 SPACES REO'D O PROVIDED O . License Number LIc Class LIMITED TIME USE , Contractor Date DATE DATE O ' - FROM TO jam 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 SI NATURE mess and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic or Reg No Date HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS/ ON LOT AN D,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 °• ;2'1 660 A , EJ1, PROVIDED � ' _ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code) ,1,0 • 8 Q 5'0 PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY .• • • 8,Q 5 0 0 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) 1, , 0 3.0 8-i-'8 5 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 hereby authorize representatives of this County to enter t above-mentioned pro rty for inspect n pu ose� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per�iStee Date 0