HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Miscellaneous_8/11/1997_Quality and Quantity Kitchen (QQ Kitchen) WORKERS'COMPENSATION DECLARATION CE 875 (11-84)4
CE MISCELLANEOUS APPLICATION
87
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`Yorkers'Compensation Insurance,or V
,I a.certifieu copy thereof(Sec. 3800,Lab.C.) 42
.
"L Policy No. Company FOR APPLICANT TO FILL IN eu,LD,Nc
ADDRESS 'T7
Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS 9441_ 1 2 LAS TUNAS
1 ! Certified copy is filed with the county building inspection LOCALITY - NEAREST.
department. CROSS ST.
Date Applicant NEAREST DIS NOO� GRO�IP TYPE P SSED BY
I
CROSS ST. ��/{ CONST.
+ CERTIFICATE OF EXEMPTION FROM WORKERS' 3 LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP "'G"`''AY STATE MAJOR SECOND LOCAL
NO: (CIRCLE}
7NNO. OF BLOCS.
(This section need not be completed if the work involved TRACT OW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (S100) or less.) USE of
y SIZE OF LOT EXISTING BLDG. }
I certify that in the performance of the work for which this L
permit is issued, I shall not employ any person in any manner �( OWNER &TKA '/9— Y'//Ft0PERTY
so as to become subject to the Workers' Compensation Laws./\ MAIL OCCUPANCY GROUP —
I ADDRESS 533 14TH STREET =
Date Applicant
TEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY SANTA MONICA NO.
_ _-
ZZ
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. Knowl.
deemed revoked.
IPanic Devices
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION
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 Exlrs
ness and Professions Code, and my license is in full force and & KITCHEN
effect. PARKING REQ"D PROVIDED I
SPACES
h
License Number Lie. Class
LIMITED TIME USE
L'
N Contractor Date GATE - OATE
Z 1 FROM: TO:
I am exempt IIOm the I1CenSing.IeQUIIemenL$ as I am a 1 INSPECTOR'S
x } licensed architect or a registered professional engineer 1 SIZE OF VO. OF SI NATURE
Z acting in my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code_).
FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date Q `(
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
+ License Law for the following reason (Section 7.031.5, Busi-
ness and Professions Code): NO. PARKING -
SPACES PROVIDED tit ii illi••_l.11�.3i....i. ,... _ '
t, as owner of the property; will do the work and the
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
1i for the performance of the work for which this permit is
issued(Seca 3097,Civ. C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
J ( PERMIT FEE
I certify that I have read this application and state that the
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-menti ned property fyin,,ection purposes.
1 pSEE REVERSE FOR EXPLANATORY LANGUAGE
Sisrna u4 of Permittee Date.