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HomeMy Public PortalAbout9033 JAYLEE DR_Miscellaneous_1/18/1981_3/4 bath, den WORKERS'COMPENSATION DECLARATION ..,.-,---,' 76M4'44. (n��p (�pp pp g� ��,pp [� pp pp APPLICATION p /� �p ?r. CE875 (2-80) ; .. EV.IS, EILL�ANEOUS APPL 'CATIOr� Y ii rebAffirm that I have a certificate of consent to self. 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 BUILDLNG R' ADDRESS �. ❑ Certified copy is.hereby furnished: DDNG ©A y '. LOLOCALITY ,. - :ADDRESSING 7 S O Certified copy is filed with the county building inspection" ALITY NEAREST department. LOC , CROSS ST. r0 ' Date Applicant = EAREST •r"• • DISTRICT NO. G UP TYPE PROCESSED BY .CROSS ST., _•.>-.. .e.ror ,S.O� ..3 CONST: .� CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL DESCRIPTION LOT NO. 'BLOCK = COMPENSATION INSURANCE - rvoP OD-3'(cGHWAIRCLESTATE MAJOR SECOND.LOCAL 'Q tUs OF BLDGS. O (This .section need not be completed if the work Involved" TRACT W ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less:) _. U OF SIZE.OF LOT STING BLDG. �J - Cr. I certify that"in the performance of the work for-which this permit is issued, I shall not employ any person In any manner NER F- so as to become subject-to the Workers' Compensation Laws. AIL U n OCCUPANCY GROUP �I �,/Q�. �� ADDRESSJq 07G raj d Date' Applicant J[,(/ /n//�Q //jj ./ /�l.r •'10/f• TEL. # /.— / i z NOTICE TO APPLICANT:.If, after making this Certificate of CITU No. {/ OCCUPANT LOAD _ Exemption, you should become subject to .the Workers' APPLICATION 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 deemed revoked. Q No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION - Panic Devices ❑, I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing'with Section 7000) of;Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING effect. SPACES REO'D U PROVIDED License'Number. Lic.Class e LIMITED TIME USE L.�J Contractor Date DATE DATE FROM: TO: - lam exempt fromthe licensing`.requirements as I am.a•, / f , licensed architect "Oi a registered .professional engineer SIZE OF NO. OF ! //�//✓ {�g• INsdEyero R's `. acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE IneSS and P[OfeS510I1S Code). -PRESENT USE OF BUILDING FINAL APPROVAL �+• �- Lic.or Reg.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. z'2 01.8'A License. Law for the following reason (Section. 7031.5, Busi- ness and Professions Code): NO. PARKING # o)o;0 0 3 0 SPACES PROVIDED ❑ I, as owner of the property, will do the ,work'and the structure is not intended or offered for sale (Section 2 °;° 611','00 '7044, Business and Professions Code). PROPOSED USE OF BUILDING `O 10.0 = 6.,.10 0 0 CONSTRUCTION LENDING AGENCY 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. .Lender's Address I certify t.hat I have read this application and state that"the PERMIT FEE 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-mentioned pro erty for inspection purposes. SEE REVERSE.FOR EXPLANATORY LANGUAGE-, Signature of Perm' tee Date