HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Miscellaneous_1/20/1989_Unit #A l
PORKERS'COMPENSATION DECLARATION CE 8754(11-84) M I SC E L LA N E O USA P P L I C A T I O N
I he»bby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
ins�",e,,,��of'a certificate of Workers'Compensation Insurance,or
a ce`rl.fied copy thereof(Sec. 3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
Certified copy is hereby furnished. - nD.REss ADDRESS w66 ►�( /]T!__� LOCALITY
DCertified copy is filed with the county building inspection OCALITYNEAREST
department. E Ke— CROSS ST.
Date Applicant NEAREST N� J �.tl r 0 , p DIST ICT NO G TYPE PROC ED BY
CROSS ST. I/ wIV D( v 5 /] CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SEC N LOCAL
NO. OF BLDGS.
(This section need not be completed if the work Involved - TRACT NOW ON LOT USE ZOVE 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. o
permit is issued, I shall not employ any person in any manner OWNER OF YV1�C�W y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP E02
o
ADDRESS ! �� ��` I.—
Date Applicant ,,,
NOTICE TO APPLICANT: If, after making•this Certificate of CITY S—Wp� No� OCCUPANT LOAD
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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PER IT ❑ (LIST ITEMS BELOW) i
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
effect. PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF PROM• 70• INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL
• PRESENT USE OF BUILDING !/—
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS lop
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
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I✓
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
• 's Address PROPOSED MAX. OCC. -
Lender � •
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
ordinances and State laws relating to building construction, ^�
hereby authorize epres tatives of this County to enter TOTAL FEE c�(�.J+I o
u on above-ment' ed perty for' spection purposes.
EE REVERSE FOR EXPLANATORY LANGUAGE
Signatu of Permittee Date - I