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HomeMy Public PortalAbout6203 GOLDEN WEST AVE_Miscellaneous__ WORfiERS'COMPENSATION DECLARATION CE 875(�1-84) M I SC E L LA N EO U S APPLICATION {� CE 875 LJ I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation insurance, e,or a certified copy thereof(Sec 3800,Lab.C) _ Policy No Company FOR APPLICANT TO FI LL IN BUILDING n ADDRESS ��03 Certified copy is hereby furnished. acoeEss p„� ,� LOCALITY l FCertified copy is filed with the county building inspection LOCALITY E ' NEAREST department CROSS ST Date Applicant NEAREST �0 j _ DISTRICT NO GROUP TYPE P CESSED BY CROSS ST N �^� 9 2 CO N� CERTIFICATE OF EXEMPTION FROM WORKERS' LE 6AL 4 /) "f COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO (clwcLH) 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 CD permit is Issued, I shall not employ any person m J any manner OWNER o so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 3 U ADDRESS62n a ~ Date Applicant `,•�� ! A- �/ uJ NOTICE TO APPLICANT• If, after making this Certificate of CITY NO Zxf /'U T'r OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE 4 1P e4 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 L effect. - /{ geg /A�J PARKING SPACES REQ'D PROVIDED I ` l J License Number Lic. Classlz-- G �+ 7-n aeCi9 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 m my professional capacity (Section 7051, Bus- EXISTING BLDG. ©. STORIES SIGNATURE mess and Professions Code). PRESE! USE OF BUILDINGFINAL APPROVAL ] (/ Lic or Reg.No. Date J'z -`! in HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _j ON LOT AND'USE �,":-, � I hereby affirm that I am exempt from the Contractor's '€'T License Law for the following reason (Section 7031.5, Busi- 77 -- = ness and Professions Code). No. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED � I i EN`:, structure is not intended or offered for sale (Section 7044,Business and Professions Code). 1 I 1 234 - 45 CONSTRUCTION LENDING AGENCY PROPS D USE OF BUILDING IL.:F H I hereby affirm that there is a construction lending agency . I.'H916E 16E for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name ' PROPOSED MAX occ. 5.33;1 Lender's Address �{� j•+:[i� L C'iIl i_ — I certify that I have read this application and state that the PERMIT FEE above information is correct I agree to comply with all County ISSUANCE FEE , p ordinances and State law relating to building construction, II and h eby authorize re sentativ of this County to enter TOTAL FEE upon a above-m do pert fog inspection urpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permrtt Y9Dat i 1