HomeMy Public PortalAbout5924, 5924 1/2, 5926, 5926 1/2 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875 I
I herebor c
afert that I have a certificate of consent tself
Insure;'or a certificate of Workers'Compensation Insurance,
COUNTY OF.LOS ANGELES BUILDING AND SAFETY DIVISION
a certifie;,copy thereof(Sec 3800,Lab C). .
Foiicy No. Company FOR APPLICANT TO FILL IN BUILDING
AD DR E55���/
❑ Certified copy is hereby furnished BUILDING ``''`'
ADDRESS a d/ L LD {tel LOCALITY - -
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
,department. / CROSS ST. -
Date
•r. -Date Applicant NEARES e` (� DISTRICT NO GROUP TYPE P CESSED BY
CROSS .C/�S �Ul�!/� �(�/7� 0� CONST. -
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J ��I
COMPENSATION INSURANCE DESCRIPTION Lor No. / BLOCK MAP HIGHWAY
(CIRCL3) STATE MAJOR SECOND-LOCAL
/f NO. OF BLDGS.
(This section need not be completed if'the work involved TRACT NOW ON LOT ' USE Z.N. SPICIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) j� uof
SIZg OF LOT -5C) gX19se TING BLD
I certify that in the performance of the work for which this ��';�/�/' �1
permit is issued, I,shall not employ any person in any manner OWNER OF 13u//�/yC ��(1/' &W0 60MIL s�
so as to become subject to the Workers' Compensation Laws. MAIL (� //w�[Q %//�(//-�{e '//j/y] OCCUPANCY GROUP
Date ApplicantADDRESS ,,,
NOTICE TO APPLICANT: If, after making this Certificate of CITY � N0�� r R� OCCUPANT LOAD N
Ekemption, 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 oI 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
9 (commencing'with Section 7000) of Division 3 of the Busi ❑ (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code, and my license is in full force and N
effect (/�/ E55 • 14 PARKING
SPACES REp'D J_T PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting m my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ROM. To SIGNATURE
mess and Professions Code). v !`f./ - FINAL APPROVAL ��s-1 1
Lie.or Reg.No Date PRESENT USE OP BUILDING V�L�I I,��C� rte® 1
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS D/�,J IF'PC./`,i.(.[,J /�nA/� - f(� N � FEE
ON LOT_AND USE -
I hereby affirm that I am exempt from the Contractor's D
License Law for the followingreason (Section 7031.5, Busi I {vp
ness and Professions Code). NO. PARKING ✓ '13000-131301 `�f�� `
F11, as owner of the property, will do the work and the SPACES PROVIDED /(�� 4 1-' Pri 1:4&
structure is not intended or offered for sale (Section – (:
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
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 aCd
PERMIT FEE J�
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 r
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
X
Signature of Permittee Date