HomeMy Public PortalAbout9445 1/2 LAS TUNAS DR_Miscellaneous_2/11/1997_Ochoa Jewelers WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) M ISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES l BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or ,
certified copy thereof(Sec. j800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDINGf�",,2
ADDRESS. 7
Certified copy is hereby furnished. IL°'NG ��//'S" / LI�� •TLr�As1211/�'
- X I ADDRESS 7 yy LO CA L'ITY
EJ Certified copy is filed with the county building inspection LOCALITY ! G 47/7?V CROSS sT.
department. 3CY
Date Applicant NEAREST /�� J� DISTRICT NO. GROUP TYPE p CESSED BY
CROSS ST. �.0 AUc _ X CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /O
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NOOF BLDGS.
(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
SIZE OF LOT EXISTING BLDG. r
I certify that in the performance of the work for which this °;
permit is issued, I shall not employ any person in any mannekX ER of buil din g7i�APiL C-i%Y.dft/'e� 0-5 ® `'
so as to become subject to the Workers' Compensation Laws. MAIL 9 } �/, d_C_��j' p� OCCUPANCY GROUP Vin,
ADDRESS 733 /I''vR7e /Y/fI.
Date Applicant C-
NOTICE TO APPLICANT: If, after making this Certificate of CITY $47 wD /}i1aviewl ITvo�' 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 USE GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) a
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 anX
e of business PARKING
effect. REQ'D PROVIDED
_ SPACES
License Number Lie. Class Oc��✓I� ��L r
LIMITED TIME USE
Contractor Date DATE
FROM:
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer slzE GF No. OF INSPECTOR
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN
AT E
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date (�J
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS v ��
ON LOT AND USE I2 i
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
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).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
1 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 1 have read this application and state that the PERMIT FEE
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 ize represent i this County to enter TOTAL FEE 25.00
upo a me pro r inspection purposes.
r� SEE REVERSE FOR EXPLANATORY LANGUAGE .
Xr - ? XX
Signature of Permittee Date