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Home My Public Portal About6058 GOLDEN WEST AVE_Miscellaneous__ WI KERS'COMPENSATION DECLARATION M I S C E L LA•N E O U S .APPLICATION ` CE 875 I neieCE875 (2-80)by affirm that I have a certificate- consent to self COUNTY OF LOS ANGEL'ES BUILDING AND SAFETY DIVISION insure,-or a certificate of Workers'Compensation In"surance,or a certified copy thereof(Sec 3.800, Lab_ C.) I .f Policy No Company FOR APPLICANT TO IL IN BUILDING �1 t" 1 1, 1 _ ADDRESS VJ _ ❑ Certified copy is hereby furnished - BUILDING �� f �4 LOCALITY ❑ _ ADDRESS - - Certified copy is filed with the county building inspection NEAREST , department LOCALITY CROSS ST Date Applicant NEAREST h DISTRICT NO GRQUP TYPE / PROC SSED BY CROSS ST. a J i tO � CONST N CERTIFICATE OF EXEMPTIO ,FROM WORKERS' LEGAL ti IY/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP "^/ HIGHWAY } + Ho p� (CIRCLE) STATE MAJOR SECON LOCAL a s- - ' NO •OF BLDGS. I- , (This SOCtIOn need not be completed if the work involved I TRACT NOW ON LOT USE ZONE 'SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) -_ USE OF e - " SIZE OF LOT, EXISTING BLDG. r, - I certify that in the performance of-the work for which this Q permit is issued, I shall not employ any 'person in any manner OWNER �//f/' (•— . so as to become subject to-the Workers' Compensation Laws MAIL, �// %/�/)_�l1 v///}��I/V�/O'� OCCUPANCY GROUP W ' - - ADDRES Y- /! Lam✓ DV V ✓ - d Date Applicant N NOTICE TO APPLICANT If, after making this Certificate of CITY NOLkp, 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. El deemed revoked- i� - PenIC DBVIC2S El ' LICENSED CONTRACTORS DECLARATION— occupprvcv INSPECTION I hereby affirm that 1,am licensed,under provisions of Chapter SAFETY PERMIT i (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 dO 67 ) PARKING. effect. SPACES PROVIDED REQ'D t LL��JJ License Number Lic-Class ' LIMITED TIME' USE Contractor Date - DATE DATE ❑ - - FROM TO / 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 sn my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S GNATURE iness and Professions Code) PRESENT USE OF BUILDING FIMAL APPROVAL Lic.or Reg.No Date NO'. OF EXISTING BUILDINGS f HOME OWNER-BUILDER-DECLARATION ON LOT AND USE I hereby affirm that I am exempt fiom the Contractor's 91.54,8A- , ;# � � Q , License Law for the following reason (Section 7031 5, Busi- , ess�and Professions Code) � �NO PARKING • • 8 Qj V I, as ownSPACES PROVIDED er of the propeity, will do the work and the • •-• 8 Q 5 0Z tructure is not intended-or offered for sale (Section •- 7044;Busmess and Professions Code). _ - PROPOSED USE,OF BUILDING Q220_'85 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the ,work foi which this permit is issued(Sec 3097,CN,C) Lender's Name PROPOSED MAX OCC. Lender's Address PERMIT FEE I"certify that 1-have-read this appilcation-and state that the above information is correct I agree to comply with all County ISSUANCE FEE isV 0rdmances and State laws relating to building construction, TOTAL FEE M—he eby authorize re sentatives of•this County to enter o t ' a 7qve-me do prope y for inspects n purp"sea SEE REVERSE FOR EXPLANATORY LANGUAGE Wa /t �i !JU ignature of ermitt a Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 IYhereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES \ BUILDING AND SAFETY DIVISION ifisure, or a certlfi(%te of Workers'Compensation Insurance,or �,' a certified tc�py thereof(Sec. 3800,Lab.C Policy No Company FOR APPLICANT TO FI LL IN BUILDING �^y ADDRESS Certified copy is hereby furnished. BUILDING. LOCALITY SS j) Certified copy is filed with the county building inspection LOCALITY ! NEAREST department. CROSS ST Date Applicant NEAREST. - DIGSRI�T\ G CONS N;qOEY CROSS ST. •� DT 10 CERTIFICATE OF EXEMPTION FROM WORKERS' L'EGkLI COMPENSATION INSURANCE DESCRIPTION 'LOT No. N BLOCK MAP HIGHWAY Ho (CIRCLE) STATE MAJOR SE CO LOCAL C > O. OF BLDGS. (This section need not be completed if the work involved TRACT �. N �l 1\ NOW ON LOT USE ZONE SPECIAL CONDITIONS by the, permit is for one hundred dollars ($100) or less.) , 0 x y�D USE of I certify that in the performance of the work for which this SIZE OF Lor EXISTING BLDG. O permit is issued, I shall not employ any person in any manner OWNER CYr C.JCVer _ C; so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o \kq ~ Date ADDRESS Applicant � � N w NOTICE TO APPLICANT If, after making this Certificate of CITY NOL 8�g1� OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICA ION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked ❑ E] No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PER ❑ (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 effect. PARKING REgD PROVIDED t/7 t SPACES II��JJ License Number Lia 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 US STORIES UE SIGNAT E mess and Professions Code). FINAL APPROVAL , PRESENT USE OF BUILDING Lie.or Reg No Date S• YY►� 1 HOME OWNER-BUILDER DECLARATION NO. OF E STING BUILDINGS ON LOT AND USE ACCT"g I hereby affirm that I am exempt from the Contractor's flp �NI License Law for the following reason (Section 7031 5, Busi- 33-,07 UV" ness and Professions Code). NO. PARKING 1 ITEMS ElI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section _ TOTAL av .00 7044,Business and Professions Code). 'rJ CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 0.30"0 I hereby affirm that there is a construction lending agency CHANGE .00 for the performance of the work for which this permit is issued(Sec.'3097,Civ C.). Lender's Name 0000-0001 7/ 1/90 PROPOSED MAX. OCC. Lender's Address PERMIT FEE 0 0 8702 1 AM 10:00 � 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 3. Q 0: ordinances State laws relating to building construction, and hereb thorize representatives of this County to enter TOTAL FEE upon th ve- entioned property r sect n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Datea �qa