HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Miscellaneous_10/16/2001_Subway WORKERS' C'OMPENSAHON DECLARATION i0A1.44 MISCELLANEOUS APPLICATION
20-00611DPW 12.'SU
hereby affirm that I have a ccrtificaie of consent Io sellCOUN'I-Y OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation In,tlIMIce, or Il
a certified copy thereof (Sec. 3800, Lab. C.)
d Policy No. Company FOR APPLICANT TO FILL IN BUILDING %ell If (g 11NAS f
BU DING ADDRESS r ADDRESS
El Certified copy is hereby furnished. (�4/� // AS ���� k LOCALITY
❑ Certified copy is filed with the cowuy building inspe'_tion CITY �L IP NEAREST ry ^
department. `71?(S 0 CROSS ST.L
Dale _ Applicant SIZE OF LOT�s/)^ /j NO.OF BLDGS.NQW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
7 ,/ J\ j3 CONST. I'
C'ERTIFICAIF OP EXEMPTION FROM WORKLI:S' TRACT BLOCK LOT NO. `
�J C'OMPLNSM]ON INSURAW E MAY NIGHWAY
NO. ICIRCLE, STATE MAJOR SECOND LOCAL
(This section need not be contpleled il' the Work in%0ved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permil is for one hundred dollars 11-,11001 or !Icss.)
I Certify that in [lie performance ol' the %k Ol"k for which this OWNER ) TEL N0.
t
permit is issued. I shall not ens hi In erson in ;Illy manner CHAAJ 9 A4 LJ
so as to become subject to the Workers' Compen,ation Caws. ADDROCCUPANCY GROUP r..
25 NS�N 70 A-) ®�/J
Date Applicant -._ _ __. - CITY ��� M A IQ . n ZIP
NOTICE TO APPLICANT: If. alter making this Certificate OCCUPANT LOAD
of Exemption, you should become.subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE:j
Comply Will) SLICK provisions or this permit shall be LICt1ned TRAILER USE❑ GEOLOGY INSPECTION❑
1 revoked. y No Spec.Know[. ❑❑
OCCUPANCY INSPECTIONIK Panic Devices
LICENSED CONTRACTORS DEC'LARMION
3 I hereby affirm that I am licensed Linder provisions 111 C hapter SAFETY PERMIT❑ ILIST ITEMS BELOW t
9(commencing with Section 7000)of Division 3 of the Business R NO.OF EXITS
and Professions Code.and my license is in full force and effect.
PARKING
p I License Number Lic. Class �/ , — SPACES REO'D D PROVIDED O
CL„tl,;,cl,,, Dale LIMITED TIME USE
I DATE DATE
❑ I am exempt ftrr.; the licensing requirements as I ails a FROM: TO:
licensed architcc; .)r a registered professional en!Jriecr
f. 1 SIZE OF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051. 13u';lness { 2 Al I--
,�) EXISTING BLDG. 1�1�J � -- STORKS y - SIGNATURE
and Professions Cock). �9 n/
LIC. Or Reg. No. Date PRESENT USE OF BUILDING I FINAL APPROVAL D U✓0/ /
HOME OWNER-BUILDER DI'.( LARAIION NO.OFLXIsrINGBUILDINGS
ON LOT AND USE l
hereby affirm that I and exempt frons the Ctintroctor's.License
Law for the following reason (Section 7031.5, Business and _
Professions Code): NO.PARKING /` 2
,I El Las owner of the properly. ,Dill do IJ1e 1",rk : Ll u, thSPACES PROVIDED V e ----------
SIFLICILII-C IS [lot intended of 011eled IOI Sale (Scciion 7I44, PROPOSED USE OF BUILDING
I Business and Professions Code).
QV P,AIJ
CONSTRUCTION LENDING AGENCY
hereby affirm that there is it construction lending agelic) Ila' __ I
the performance of the work for which du% perms( is issued
l
(Sec. 3097, CIV. C.). PROPOSED MAX.OCC.
-) Lender's Name _-__
..-___— --__..-._. _ .._ .. APPLICANT lPHINT) TEL NO.
Lender's Address :._...._._
I - - �--- - - ADDRESS ,
I certify that 1 have read this application and state Thal the
above information is correct. I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building construction,and
hereby authorize representatives of this County to enter LIP011 ISSUANCE FEE
the above-mentioned proper( for inspection purposes.
TOTAL FEE
M SEE- REVERSE ,FOR EXPLANATORY LANGUAGE
v Si r of Permit e hu,
� 1
ti-