HomeMy Public PortalAbout9445 LAS TUNAS DR_Miscellaneous_8/30/1993_occupancy inspection % �.
WORKERS'COMPENSATION DECLARATION CIE 875 MIS E L L g N EQ e p$ APPLICATION.
. CE 875(11-84) i.. /"i `.�l,Jl
I heteby-af£frm• 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 1 11 I fl
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. CompanyFOR APPLICANT TO'FILL IN BUILDING n
ADDRESS
Certified copy is hereby furnished. . BUILDING ZJ S J
DDRESS f{�/� /�'-a.11 Ag /J
• LOCALITY
Certified copy is filed with the county building inspection — '
g p LOCALITY �`'—^ �/�]00 NEAREST
department. tGM (�( / .ROSS ST.
Date Applicant NEAREST DISTRICT NO. GBPUP TYPE HrPPCESSED BY
CROSS.ST. _ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
.COMPENSATION INSURANCE DESCRIPTION LOTNO. BLOCK MAP HIGHWAY
rvo. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF 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. d
I certify that in the performance of the work for which this
permit is issued, I shall not employ-aily person in any manner OWNER .� s�
/� �c-I-t4
so as to become subject to the Workers' Compensation Laws. MAIL ^—' OCCUPANCY GROUP o
Date Applicant ADDREss L4 q. i U�. S' I—
�� G'' (JtJ ��V w
NOTICE TO APPLICANT: If, after makingthis Certificate of clrY OCCUPANT LOAD oOn
_
Exemption; you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with -comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION, -
deemed revoked. ❑ ❑ No Spec. Knowl. El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM( ❑ (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. m_ i S i PARKING SPACES REQ'D PROVIDED E
. -•
License Number Lic. Class 1z:;AA
LIMITED TIME USE
Contractor Date - DATE DATE
0 I am exempt from the licensing.requirements as I am a "FROM: TO:
licensed architect or a registered professional engineer SIZE'OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG., STORIES SIGNATURE
'inessandProfessionsCode). FINAL 'APPROVAL
PRESENT US F.BUILDING
Lic.or Reg.No. Date ' T
V0 Or
140ME OWNER-BUILDER DECLARATION NO. OF TING BUILDINGS I
ON LOT AND USE
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
SPACES PROVIDED
I, as owner of the property, will do the work and the t=; !
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED u F BUILD( G
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.). t
Lender's Name
PROPOSED MAX. OCC.
Lender's Address •
G(/
I certify. PERMIT FEE that I have read this application and state that the 2
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-mentioned property forinspectionpurposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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