HomeMy Public PortalAbout10732 DAINES DR_Miscellaneous__ i
-.WOR $RS'COMPENSATION DECLARATION 76M444
P' CE 875 (2-80) MISCELLANEOUS. APPLICATION
I yteby affirm cert that I have a certificate ati consent Insurance,
m self' . COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '.
Us
LL[[e, or a certificate of Workers'Compensation insurance,or
a ceh"ied copy thereof,(Sec. 3800,Lab. C.) _
i
Policy.;o. CompanyBUILDING
FOR APPLICANT.FOR LIE IN ADDRESS fo73 Z p,41/llES pe 7
❑ Certified copy is hereby-furnished. Bu1LDlrv. 'moi ��jj &,r /1 /t !' . Loc ALITY /' s /'l Q y �1
. AODRE ss I ` G.. 'I (/ K'. r,�sH LG-Ct rt,'. �' �!♦' ( CJ O
Certified copy is filed with the county building inspection - rvew REST
department LoepuTv -r ' Ch [�!'j G,'+6 clxoss'sT. ,p4-s/2Slir it'it/t O :✓
LC � t
Date Applicant NEAREST ' v DISTRICT NO GROVP TYPE- PR CESSED BY
CROSS ST. XR-,S IA,4 Al 6/4/ h xn
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL c1
COMPENSATION INSURANCE DRECEIPT Iory LOT NO. icMAr
NO (CIRCLE) STATE MAJOR SECOND LOCAL a
NO. OF OLDGS. O
(This' section need not be completed If the work involved TRACT 3 (p _ NOW ON LOT_ USE ZONE SPECIAL CONDITIONS '
by the permit is for one hundred dollars (SI00) or less.) 'V
l USESOF /�f '
SIZE OF LOT X ( LO E%ITIN G'O LD G.rL K JS1 • _ 0
1 certify that in the performance of the work for which this _ O
permit is issued, I shall not employ any person in any manner OWNER , . �!U L L �.�—. F_
so as to become subject to the Workers'-Compensation Laws. 'YA ^ �$ Tt OCCUPANCY GROUP
MAIL � //r W
_ ADDRESS
Dare Applicant I� 3 Z,v Q !n
NOTICE TO APPLICANT: If, after making this Certificate of CITY (- /t LG Cf No �r(K t,p,✓��' OCCUPANT LOAD Z.
Exemption, you should become subject to the Workers' qpp LICA ION 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. KnOWI. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION - OCCUFANcv INSFEDTr.sl Panic Devices ❑
I hereby affirm that i am licensed under provisions of Chapter .SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF ..ITS
9 (commencing with Section 7000) of Division 3 of the Bosi
ness and Professions Code, and my license is in full force and fir- ^ PARKING effect, 6 `r `v C� 41 REO'O E= PROVIDED
' yy qq S,Ac Es
License Number Lie. Class A -P k• -
LIMITED TIME USE
Contractor Date' - o.TEDATE
I am exempt from the licensing requirements as'l am a.
licensed architect or.a registered professional engineer SIZE OF ,- p rvo. of INSPEcToa'S
acting in my professional.capacity (Section 7051, Bus EXISTING BLOC. �(� 7,(,.p STORIES SIGNATURE
mesa and Professions Code). PRESENT USE F BUILDING - FINAL APPROVAL S ///G/y1
O �Ja-�( '/ .
Lie.or Reg.No. Date-
HOME
L
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 7031.5, Busi-
ness and Professions Code): I SP..PAR ICING
$P.0.S PRONTO ED - -
❑ 1, as owner of the property, will do the work and the. I T'j_I`'i:
structure is not .intended or offered for sale (Section
7044, Business and Professions Code). j(I 00
PROPOSED USE OF BUILDING -
CONSTRUCTION LENDING AGENCY [i—
.I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 11-Irif�VC. 1=11'
issued (Sec. 3097,Civ. C). • - -
Lender's Name
, PROPOSED MAX. OCC. ,
Lender's Address
IPERMIT FEE. - - -
1certify that I have read this application and state that the - .f - •], (-5; ;
.hove information is correct. I agree to comply with all County ISS UA NCE FEE
ordinances and State laws relating to building Construction, TOTAL FEE ) 44 -
and herebv authorize representatives of this County to enter
upol he above-ment'one pr erty for inspection PIKPOSys. I EE REVERSE FOR£ LANATORY LANGUAGE
Signature of Permittee Ulate - -