HomeMy Public PortalAbout9576 DAINES DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
�- APPLICATION {�
I hereby affirm th� I have a certificate of consent to self COUNTY OF LOS ANGELES' BUILDING AND SAFETY DIVISION �J
Insure, or a certificCe of Workers'Compensatidn Insurance,or
a certified wpy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS,
❑ Certified copy Is hereby furnished BUILDING
��I �sP J / LOCALITY'
❑ Certified,copy is filed with the county building inspection NEAREST
department LOCALITY CROSS ST 11-40
Date Applicant NEAREST n p /+ DISTRICT NO GggUP TYPE PROCESSED BY
CROSS ST Te t- "C. V(� /{/ �� CONS V
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �Id
COMPENSATION INSURANCE NO OF SLOGS DESCRIPTION LOT NO BLOCK MAP /',/ IGRWAY �}
I .0 L{rJ (CIRCLE) STATE MAJOR ECOND LOCAL a
(This section need not be completed if the work involved'
TRACT d`O NOW ON LOT USr'ZONE SPE IAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.) �/ L USE OF +
SIZE OF LOT ���X �+ -�� EXISTING BLDG S/ ' - V'
I 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 TWC7 — (—
so as to become subject to the Workers' Compensation Laws MAIL �/ C y+ OCCUPANCY'GROUP .. �j W
ADDRESS JA,T.��V �0 t -_�
Date Applicant p p} p
NOTICE TO APPLICANT If, after making this Certificate of CITY e G I rvoL�v ell l"d(1 OCCUPANT LOAD Z
Exemption, you should become 'subject to the Workers' gppL CATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE E] 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 Q (LIST ITEMS BELOW) - NO OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the,Busi-
ness and Professions Code, and my license is in full force and +
effect 11Q(Il PARKING REQ'D
SPACES PROVIDED
` 'n`0
' �
License Number Lic Class A1ht Orn
LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM ' .TO -
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR'S
,acting,in my professional capacity (Section 7051, Bus- EXISTING BLDG 56 STORIES f IGNATURE
iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date
-
f iSt A
HOMEOWNER-BUILDER DECLARATION NO of Exls NG BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ;F 7 5 S9 k
License Law for'the following reason (Section 7031 5, Busi-
ness,and Professions Code) NO PARKING' # o e o • 3 0
SPACES PROVIDED
❑ I, as owner'of the property, will do the work and the o • 8 Q 5'0
structure Isnot Intended or offered for sale (Section' '
7044,,Busmess and Professions Code) PROPOSED USE OF BUILDING a O O O 8 0.,5,0 U
CONSTRUCTION LENDING AGENCY x , 0 7,2 9 t 8 7 -
I hereby affirm that there is a construction lending agency nil eil
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 PERMIT FEE U
I certify that I have read this application and state that the
above Information is correct I agree to comply with all County ISSUANCE+FEE jOI_
ordinances and State laws relating to building construction, /ti v
and hereby authorize representatives of this County to enter TOTAL FEE (J
upon the above-mentioned property for inspect io purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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SiAnattIre of Perm&jee Dat