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Home My Public Portal About5637 GOLDEN WEST AVE_Miscellaneous__ i 'WORKERS'COMPENSATION DEC)�ARA-ION• Lr 76MIT44 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 a certified copy thereof(Sec 3800, Lab. C) " Policy No. Company FOR APPLICANT TO FILL IN BUILDING, - ElCertified copy is hereby furnished BUILDING LOCALITY ADDRESS e. ❑ Certified copy is filed with the county building inspection NEAREST department, LOCALITY CROSS ST. Date Applicant NEAREST (� ` DISTRICT NO GROUP TYPE PROCESSED BY CROSS ST CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE MAP HIGHWAY STATE MAJOR SECOND LOCAL d ' rN O. OF BLDGS NO (�fJ (CIRCLE) - (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q by the permit is for one-hundred dollars ($100) or less.) U USE OF, SIZE OF LOT EXISTING BLDG /� ; r I certify that in the performance of the work for which this A( permit is issued, I shall not employ any person I any manner OWNER, f— so as to become subject to the W rkers' Com atio Laws. MAIL OCCUPANCY GROUP �, I ADDRESS 'l ��e� S%' 1].. Date S 3 Applicant - _ NOTI O APPLICANT If, after making this rtificate of ` CITY - �, NoL Z�S �Q �- OCCUPANT LOAD - z Exemption, you should become subject to the WorkersAPPtICATION FOR EXIT HARDWARE Compensation,provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE I • GEOLOGY INSPECTION-O No Spec. Knowl. ❑ ' deemed revoked LICENSED CONTRACTORS DECLARATION occuaANCY,INSPECTION_ Panic Devices ❑. 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. C1ffeCt SPACES REq'D O PROVIDED S a II��JJ 'License Number Lic Class LIMITED TIME USE ' Cnntractor Date DATE DATE' • } FROM ATO ,i y I am exempt from the licensing requirements as-I am a licensed architect or a registered professional engineer SIZE OF No of iI acting in my professional capacity (Section 7051; Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING F4NAL APPROVAL Lic.or Reg No Date 2 A HOME OWNER BUILDER DECLARATION NO OF E: [STING BUILDINGS �6 rJ • ON LOT AND USE - .I '# Y:0 U C 3 0 ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi-, 2°0 0 8 Q'5 0 ness nd Professions Code) NO. PARKING SPACES PROVIDED I, as owner of the property, will do the work and the 0 °•O 8 0,'5 0A structure is not.intended or offered for sale (Section 7044, Business and Professions Code) 05,0 3—'8 3 PROPOSED USE OF BUILDING ' 1 CONSTRUCTION LENDING AGENCY 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) - Lender's Name PROPOSED MAX.OCC. Lender's Address PERMIT FEE /1 - I certify that'[ have read-this application and state that the �f above information is correct I agree to comply with all County ISSUANCE FEE ordmances and State laws relating to building construction, TOTAL FEE f and hereby authorize resentatives of this Courity'to enter ' upo a above-me I e operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igna cre of Permitt e_ D e ` ,