HomeMy Public PortalAbout9450 DAINES DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS
ISCELLqNEO S APPLaCATI®A
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 Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
- ADDRESS J L�
Certified copy is hereby furnished. BUILDING yA16D C', jJfj/U�S LOCALITY
ADDRESS 7
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS Sr.
Date Applicant NEAREST y� DISTRICT NO. GROUP TYPE PR CESSED BY
CROSS ST. /�� `�` CONST.(
,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'J �
COMPENSATION INSURANCE DESCRIPTION Lor NO., BLOCK MAP HIGHWAY
NO. (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
' / d
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
0
permit is issued, I shall not employ any person in any manner OWNER 5.>
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP /,4�/ o
Date Applicant ADDRESS LS F,
TEL. ` -zo��.3 OCCUPANT LOAD �,
NOTICE TO APPLICANT: If, after making this Certificate of CITY rvo. °-
Exemption, you should become subject to the Workers' APPLIC ION FOR EXIT HARDWARE: z
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. El
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)
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 Ze
effect. PARKING SPACES REQ'D PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date I DATE DATE
I am exempt from the licensing requirements as I am a
0 ROM: TO:
licensed architect or a registered professional engineer SizeOF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus-- EXISTING BLDG. STORIES / SIGNATURE
iness and Professions Code).
IIVAL APPROVAL 3O
'
Lic.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ^�i
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's __.I,7
License Law for the following reason (Section 7031.5, Busi- i+, -,-•, _,,
ness and Professions Code): NO. PARKING l, w j
I, as owner of the property, will do the work and the 'PACES PROVIDED
structure is not intended or offered for sale (Section 'U';'�I
7044,Business and Professions Code).
'CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING- /A✓JA/J/��� !1�/ y ~•
'�@/" V ///��� �'-I�''?; '"=•r' '`r�'
I hereby affirm that there is a construction lending agency
p
for the erformance of the work for which this permit is
issued(Sec. 3097,Civ.C.). /
Lender's Name
PROPOSED MAX. OCC. -.- •-
Lender's Address
PERMIT FEE Bv
I certify that I have read this application and state that the I 'e U-_! I. = ;
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 roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date