HomeMy Public PortalAbout9564 DAINES DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(11-84) M ISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec 3800,Lab C) t
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished BUILDING EJ A//VES LOCALITY
ADDRESSI 7V
Certified copy is filed with the county building inspection LOCALITY NEAREST
department / E/yPLE T CROSS ST
Date Applicant NEAREST -DISTRICT NO GROUP TYPE PR CESSED BY
CROSS STT L✓� D ` CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SECOND LOCAL
NO OF BLDGS
(This section need not be completed' if the work involved TRACT / LD 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 p �!I�� �/ P r
I certify that in the performance of the work for-which this _ O (O CJ o
permit is issued, I shall not employ any person in any manner OWNER Eve L S�{C/j�� y
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP
ADDRESS V
Date Applicant uJ
NOTICE TO APPLICANT If, after making this Certificate of CITY TEM Lt of 'E,8/g Z8 Z5/g OCCUPANT LOAD °
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 USEGEOLOGY INSPECTION
deemed revoked ❑ ❑ No Spec. Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
.9 (commencing with Section 7000) of Division 3 of the Busr E:] (LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code, and my license is in full force and
effect IAI /1 j / / PARKING
SPACES REq'D D PROVIDED
License Number Lie Class &�6
_ LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a
FROM TO
licensed architect or a registered professional engineer SIZE OF No OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG, STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
LIC or Reg No Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS C,
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ACCTeg
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code) 3
NO PARKING
�+3, L'7.1)
I, as owner of the property, will do the work and the SPACES PROVIDED � ITEM';
structure is not intended or offered for sale (Section
7044,Business and Professions Code) TOTAL 27 - 70
_41
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
�CHECK ��r o7.0
I hereby affirm that there is a construction lending agency r'H11E
for the performance of the work for wluch this permit is
issued(Sec 3097,Civ C)
Lender's Name
Lender's Address
PROPOSED MAX OCC 090 �-)0� i �+!
0 1
I certify that I have read this application and state that the PERMIT FEE p�2 `13.4 I M 9-'51
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 ' Q
upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee Date