HomeMy Public PortalAbout6210 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 8
CE 875 (11-84) MISCELLANEOUS APPLICATION
- CE 75
I hereby a cerci that I have a certificate of consent self 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 FILL IN BUILDING )
ADDRESS !/
Certified copy is hereby furnished. BUILDING "}
ADDRESS d� LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST
Date Applicant NEAREST DISCT OUP TYPE / PROC SSED BY
CROSS ST. O3 T NST.I/
CERTIFICATE OF EXEMPTION FROM WORKERS' v` J
LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP I HIGHWAY
NO. (CIRCLE) STATE MAJOR SEC 94 LOCAL
NO. OF BLDGS
(This section need not be completed if the work involved TRACT NOW ON LOT ! USE ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE OF, _
- d
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.C
permit is issued, I shall not'employ any person in any manner OWNER i,
MAIL y
so as to become subject to the Workers' Compensation Laws. i`OCCUPANCY GROUR
ADDRESS
a, y.
Date Applicant LU
TEL. X71 ` OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY No: V� / C0„
Exemption, 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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION [JPanic 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 Exlrs
ness and Professions_Code, and my license is in full force and -
effect. PARKING
SPACES REQ'D D PROVIDED
License Number Lie. Class /v �%� d
LIMITED TIME USE -
Contractor Date DATE DATE
EJ I am exempt from the licensing requirements as I am a
M TO
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGN URE
iness and Professions Code). FINAL APPROVAL g PRESENT USE OF BUILDING6/Y
jiLie.or Re .No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
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 and Professions Code). NO PARKING ¢ ��
I, as owner of the property, will do,the work and the SPACES PROVIDED 0,3 $',8 A
Nl
structure is not intended or offered for sale (Section �' ;`', ' �
7044,Business and Professions Code). n d •~e e •
PROPOSED USE OF BUILDING �-y: '- �•
CONSTRUCTION LENDING AGENCY i `-- `�. •`b 8 0.Jr 0
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. CCC
Lender's Address
I certify-that I have read this application and state that the PERMIT FEE a,
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
upon the above-r ention d'prcpe ty f inspectiop purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
S n re of Permittee Date