HomeMy Public PortalAbout9838 DAINES DR_Miscellaneous__ W?RKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS A PP L I CAT I O N
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. BUILDING
Company'r FOR APPLICANT TO FILL IN ADDRESS I�
❑ Certified copy'ts hereby furnished' BUILDING Dr LOCALITY LF C
ADDRESS CC..+.
❑ Certified copy Is filed with the county building Inspection NEAREST y� -
LOCALITY CROSS ST
department
Date Applicant NEAREST /� DISTRICT NO GR OI TYPE PROCESS BY
CROSS ST. ' `,•olDEV LP$/" Id 8XDLc/10 o /yV9C K�J CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL {�/y/� ' ,
COMPENSATION,INSURANCE DESCRIPTION LOT No 'lg BLOCK NO -zo (/ (C6R LE) >_STATE MAJOR SECOND LOCAL
' NO -OF BLDGS '�-
(This.section need not be completed if the,work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS•
by the USE OF - O
- ,permit. is for one hbndred dollars ($100) or less.) U .
_ L �— r.
- - SIZE OF LOT J�� J� EXISTING BLDG 1,e
I certify tliat•in the performance of the work for which this
permit Is issued, I shall-not employ any person in any manner OWNER '
so as to become subject to the Workers' Compensation Laws. tui OCCUPANCY GROUP
MAILLU
ADDRESS (9 O /O /- _ ' �_
fir _
Date ' Applicant �7 �
NOTICE'TO APPLICANT If,'after making this Certificate-of CITY ��� NE � OCCUPANT LOAD Z
'Exemption, you should become, subject to ,the' Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions,of the Labor Code,.you must forth-
With comply with such prOVlSlOnS' O[ this permit shall be TRAILER USE GEOLOGY INSPECTIONEl NO Spec. Knows. ❑
deemed revoked. ( 1:1LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic,Devices
i
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS
9'(commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is In full force and1t� S'h a_ PARKING.
effect. L! SPACES REQ'D PROVIDED
License Number LIc Class
LIMITED TIME USE
Contractor Date DATE, DATE
FROM TO
'lam exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF ,�rr ' �r'} NO OF INSPE CTOFF'9
acting m,my professional capacity (Sect ton'7051,,Bus- EXISTING BLDG.130>tI, 'lam s STORIES
Inessand ProfessldnsCode). I /A y�,4S FINAL A OVAL
1 PRESENT USE OF BUILDING .�. -�7' . '
Lic or Reg No Date -
HOME OWNER-BUILDER DECLARATION No of EXISTING BUILDINGS
ON LOT AND USE .� • r
I hereby affirm that I anti exempt from the Contractor's // C
License Law for the following reason (Section 7031 5, Bust-'
ness and Professions Code NO. PARKING O 7 O A
' SPACES PROVIDED
OI, as owner of the property, will do the work and the
structure is not,intended or offered for sale (Section o D'o 0130
7044, Businessland Professions Code) PROPOSED USE OF BUILDING
.2IiJ i,$'Q 5 Q
-CONSTRUCTION LENDING AGENCY '��
I hereby affirm that there Is a construction lending.agency o;o ,o R,Q.5 0 L'
for the performance of the work for which-.this permit Is 4,2'6'—. 8'4
issued(Sec 3097,Civ C)
Lender's Name'
PROPOSED MAX OCC.
Lender's Address PERMIT FEE
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 -
ordinances and State laws relating to.building construction, s
and hereby' TOTAL FEE
authorize representatives of this County to enter
u Dove-menti //e////d,,proper y, for inspecti/p.purobses SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee bate, ,