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HomeMy Public PortalAbout6120 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 87 5((11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES ., B TTLDING AND SAFETY DIVISION insure, or a certifi+ate of Workers'Compensation Insurance,or � _ , , � _ -y a certifieu copy thereof(Sec. 3800,Lab. C.). K• = d r BUILDING Policy No. Company FOR APPLICANT TO FILI�IN �/ 7� ADDRESS // Certified copy is hereby furnished. BUILRDING o 0� LOCALITY ESS ADD61 Certified copy is filed with the county building inspection - LOCALITY NEAREST department. C ( CROSS ST. Date Applicant NEAREST DISTRICT NO. CAOUP TYPE CESSED BY CROSS ST. �/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL A COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK © MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL OF BLDGS. NO. (This section need not be completed if the work involved TRACT O NO10 N LOT USE ZONE SPECIAL CONDITIONS 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 o permit is issued, I shall not employ any person in any manner OWNER �., ® 5' so as to become subject to the Workers' Compensation Laws. \i OCCUPANCY GROUP ADDRESS Date Applicant p NOTICE TO APPLICANT: If, after making this Certificate of CITYTrM ITvoL.%/ r� OCCUPANT LOAD Z Exemption, you should become subject to the Workers' APPLI TION 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) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and ®_ PROVIDED effect. LSC PARKING SPACES REQ'D • � � � J License Number Lic. Class LIMITED TIME USE Contractor Date ` DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as I Lma L3 as/� C3 licensed architect or a registered professional eng IZE OF NO. O INSPE CTOR'S acting in my professional capacity (Section 7051, EXISTING BLDG. STORIES �! SIGNATURE inessand Professions Code). FINAL APPROVAL 'T PRESENT USE OF BUILDING Lic.or Reg.No. Date ' ff5 � f1f C'?F— 22n70 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS1 ITERS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's TOTAL 242 _70 License Law for the following reason (Section 7031.5, Busi- rJ~ ness and Professions Code): NO. PARKING CHECK 242.70 1�rI, as owner of the property, will do the work and the SPACES PROVIDED CHANGE00 structure is not intended or offered for sale (Section CHANGE . 00 Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I D000-0001 °/22/g` I hereby affirm that there is a construction lending agency i�j f 1954 1 AM 10:44 for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. 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 U ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE a/�e� ,.70 upon the above-mentioned proper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature 0 ermittee Date