HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Miscellaneous_2/20/1997_Lupita's Cafe R'ORKERS'COMPENSATIONDECLARATION 7.6M444
CE 875 (11-84) MISCELLANEOUSAPPLICATION
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I hereby affirm that 1 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.).
Bu
A
Policy No. Company FOR APPLICANT.TO FILL IN DRESS
DDRESS
BUILDING
Certified copy is hereby furnished. X DDR ESS v{�I S (lC, LOCALITY
Certified copy is filed with the county building inspection-- OCALITY f C NEAREST
department. �yy:., t ?�G/ �� f ( CROSS ST.
Date Applicant NEAREST /meq DISTRICT NO. UP TYPE �/ P ESSED BY
CROSS ST. O/1' `fGJ/rOY/l CONST.,/`/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP• HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLOCS.
(This Section need not be completed If the Work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
slzE of LOT
1 certify that in the performance of the work for which this EXISBLDG. L,
,+TING
J
>-
permit is issued, I shall not employ any person in any marine OWNEROf bull ding
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP R-
MAIL
ADDRESS
Date Applicant u
NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL 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 USEE] GEOLOGY INSPECTION ❑ No Spec. Knowl.
❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 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 a NO.OF EXITS
ness and Professions Code,and my license is in full force a �I
effect. X Name Of businSPARKINPA CESG REQ'D 1 PROVIDED
License Number Lic. Class \ lJ ' !' tq S C1
LIMITED TIME USE
Contractor Date DATE DATE
-
FROM: TO:
El 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
r inessandProfessions Code)• FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date n `
HONIF.OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE J
1 hereby affirm that 1 am exempt from the Contractor's a i ,,,.i-i,s(li..l':•.
License Law for the following reason (Section 7031.5, Busi- �
ness and Professions Code): NO. PARKING -
1, 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).
CONSTRUC'T'ION 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
issued(Sec. 3097,Civ.C.).
Lender's Name
.PROPOSED MAX. OCC.
Lender's Address _
PERMIT FEE - -
1 certify that I have read this application and state that the 25. 00
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and.State laws relating to building construction,
and hereb ,authorize representatives of this County to enter TOTAL FEE 25.00
N-IlX
pu thve-mentine roperty f r inspection purposes.� � ( SEE REVERSE FOR EXPLANATORYLANGUAGE
XX `�77
Sienawrc of Permittee Date