HomeMy Public PortalAbout6137 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 M I SC E L,LA N EO U S APPLICATION
I hereby affirm that I have a certificate of consent to self CE 875 (11-84)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 6/_3 M, C0/ fYa i
ADDRESS /r 1//�/"/-"+///
FICertified copy is hereby furnished. BUI
ADDRESS LDING �JL -' LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY NEAREST Al artment. CROSS ST. Fes-/ '
Date Applicant NEAREST '/ II // DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST: (�./-I !/�, a CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �( '
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
rvo. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work Involved TRACT NOW ON 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 G % J
so as to become subject to the Workers' Compensation Laws. MAIL �L OCCUPANCY GROUP _ o
Date ADDRESS Applicant S w
NOTICE TO APPLICANT: If, after making this Certificate of CITY � � 07-VN OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLIC ION 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. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
Ihereby 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
effect. W �/ Ii/� PARKING REQ'D PROVIDED
License Number Lic. ClassSPACES
-��[/,/, (/� LIMITED TIME USE
Contractorff��7�— " Date v _ 9� DATE DATE
FROM: TO:
El I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE
iness and Professions Code). --------
FINAL APPROVAL .�
Lic.or Reg.No. Date PRESENT USE OF BUILDING {/
HOME OWNER-BUILDER DECLARATION NO, of EXISTING BUILDINGS y/ �"�,� -•
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness
usi ness and Professions Code): NO. PARKING
EJI, as owner of the property, will do the work and the SPACES PROVIDED ;µ Y
structure is not intended or offered for sale (Section - 7;
7044,Business and Professions Code). — - • r T
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING si ":?'; -
I hereby affirm that there is a construction lending agency A'•z;`.u=
for the,performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name _ __,.•- ;'� ;_:•
PROPOSED MAX. OCC. I-?I•;i'„'-.''•"'3?-7?�:,, ,,,, _,;ra•,,,
Lender's Address
PERMIT FEE �. 0 & 'i AF
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 a 73
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
MAL
oned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of)Permittee Date .