HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Miscellaneous_9/20/1994_Taco De Acapulco WORKERS'COMPENSATION DECLARATION
CE 875(11-84) M I SC E L LA.N EO U S APPLICATION
' CE 875
I hereby affirm 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 iJVILDING
ADDRESS
Certified copy is hereby furnished. BUILDING aL4L4 t
ADDRESS t/ J) LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department: CROSS ST.
Date Applicant NEAREST DISTRICT NO. OUP TYPE CESSED BY
CROSS ST. - �D (/ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
- OF BLDGS.
OCCUPANT LOAD z
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.[] _ No Spec. KnoWI. El
revoked.` Panic Devices E
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E]
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 EXITS
ness and Professions Code, and my license is in full force and
effect. PARKINGSPACES REQ'D D PROVIDED D
License Number Lie. Class l t 7 PICL
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
El I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF - NO. OF INSPECTOR'S
acting in my professional capacity.(Section 7051, Bus- EXISTING BLDG, STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING I
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS \
ON LOT AND USE ( �
e
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- �^ v
ness and Professions Code): NO. PARKING "\ ✓� _. __ i :tel I _
�l
I, as owner of the property, will do the work and the SPACES PROVIDED s -
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
- -
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is n
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
a �U
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,
!and hereby authorize representatives of this County to enter TOTAL FEEJr (�
upon the ab ned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ICI
Signature of Permittee Date