HomeMy Public PortalAbout9445 1/2 LAS TUNAS DR_Miscellaneous_8/7/1992_Occupancy inspection for 88 Arcade WORKERS'COMPENSATION DECLARATION
.• b"` CE 875(11-84)
MISCELLANEOUS APPL1CAT1ON
I hy affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDINGAND SAFETY DIVISIONinsure,'or
a certificate of Workers'Compensation Insurance,or
acertified copy thereof(Sec. 3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FI LL IN ADDRESS
ADDESSSS 7 y"
Certified copy is hereby furnished. wooREss ' f7 LOCALITY
F] Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE - O ESSED BY
CROSS ST. ^ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP /`HIG XW AY
rvo.�SO��-III,J (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed If the work involved TRACT NOW ON LOT USE ZONESPEC IAL'CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
Iycertify that in the performance of the work for which this SIZE OF Lor ExIsnNG BLDG. o
permit is-issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS ~
Date Applicant L�1'
NOTICE TO APPLICANT: If, after making this Certificate of CITY No� L. 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. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter
SAFETY PERMIT ❑ (LIST ITEMS BELOW),
ELOW NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code,and my license is in full force and
r
effect. - e U'1 E
�Q��� SPACES PARKING RQ•D � PROVIDED
LL��
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
DI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer ' SIZE OF No. OF INSPEcroR s
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES i SIGNATURE:
iness rReg.No. Date PRE-SENT
Lic.or Reg. /' FINAL APPROVAL
SENT USE OF BUILDING /
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O G+� �?' v-.a�
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's U �j
License Law for the following reason (Section 7031.5, ,
Busi-
ness
usi E;
ness and Professions Code): NO. PARKING -- - - ' '
I, as owner of the property, will do the work and the SPACES PROVIDED d irk ?
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING / ,1 o
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
I certify that I have read this application and state that the PERMIT FEE ez— '
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 abov mentioned property for inspection urposes.
• ` SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitte • Date