HomeMy Public PortalAbout6406 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8;6(11-94) MISCELLANEOUS APPLICATION
I hereby y rru flint I have a certificate of consent to pelf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure, or �certificate of Workers'Compensation Insarance,or
a certif led copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDR[■■
Certified copy Is hereby furnished- BUILDING LOCALITY
ADDR[// Q 55�Cf
Certified copy Is filed with the county building inspection LOCALITY N[AR[ST c-4.d Fw IA
department. 47
, CROSS
Date Applicant N15ARKST DISTRICT n OU TYr[ PR C[/SNO ■Y
CROSS
■T , ' /J/ — CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LCGAL (JO ✓✓✓
COMPENSATION INSURANCE DESCRIPTION LOT NO. I.C. MAP HIGHWAY
No. (aIRcLL) STAT[ MAJOR ■[GOND LOCAL
INC. OF ■LD GS.
(This section need not be completed If the work involved TRACT
Now ON LOT Ua15 zDN15 Sr[ C RIO
by the permit is for one hundred dollars ($100) or lea) U■E of /J
SIZE OF LOT 15X1/TING ■LD 1 / ���ev
1 certify that in the performance of the work for which this C� CD
permit is issued, 1 ahall not employ any person in any manner OWNER �( �
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o
Date Applicant AD DR c/■ B ^ t�
NOTICE TO APPLICANT: If, after making this Certiflcat of crrY NO OCCUPANT LOAD
Exemption, you should become subject to ,the Workers
Compensation provisions of the Labor Code, you must forth- APPLICATION R EXIT HARDWARE: -'
with comply with such provisions or this permit shall be rRAILER U■K GKOLOGY INQPKCTION ❑ No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY IN■P15CTIoN ❑ Panic Devices El
I hereby affirm that I am licensed under}provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bua1 ■AF ETY PtRYIT (LIST rT15Y■ ■[LOE/�
NO. of 15zIT■
mn and Professions Code, and my license is in full force and
effect Q PARKING RXQ'D 1R.111.13SPACE■
License Number Lic. Clan
/�� �y LIMITED TIME USE
Contractor lithe DAT■ DAT/
I am exempt from the licensing requirements as I am a DI
rRDYI TDI
licensed architect or a registered professional engineer SIZE OF . of s IN/FE
G R ■
acting in my professional capacity (Section 7051, But it
acting NoING BLDG. /TORI[■ ,c ■IUR[
Ines and Professions Code).
PRK2KNT U/s o ■u1LDINo FINAL APPROVAL 1
Lia or Reg.No. Data AA
HOME OWNER-BUILDER DECLARATION NO. OF 15 I/TING BUILDINGS / i}� c
ON LOT AHD USK TI ITIS 8 - 6--
1 hereby affirm that I am exempt from the Contractor's CASK 238.65
License Law for the following reason (Section 7031.5, Bud-
and Profenions Code): NO. PARKING ., ■Iyj
I, as owner of the property, will do the work and the SPACKS rROVIDED
structure is not Intended or offered for sale (Section
7044,Business and Professions Code). ! ? ,f 5
PR 0P0.15D US15 OF BUILDING � �� �I �
CONSTRUCTION LENDING AGENCY 9I3-19 1 F11 6:21
I hereby affirm that there is a construction lending agency
for the '
of the work for which this permit if
Issued(�a 3097,Civ.C.). e,41
Lender's-,Iame// rROPO■[D YAX. OCC.
Lend, �iv"dress
PERMIT RE¢
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
ordinances and State laws relating to building construction,
and hereby authorize representativ s of this County to enter TOTAL PEE
upon the abo tioned pro for Inapectfo purpoAM
SEE REVEJLS FOR EXPLANATORY LANGUAGE
ro ttee
—DaG