HomeMy Public PortalAbout9939 DAINES DR_Miscellaneous__ r
WORKERS'COMPENSATION DECLARRLTION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby a certificate
that I have.a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,dor a certt ificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.-3800,Lab.C).
Policy No. Company FOR APP LICANTTO FILL IN BUILDING
ADDRESS / 7
FICertified copy is hereby furnished. BUILDING LOCALITY
/
ADDRESS LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY ' NEAREST
department. �� W Ross ST.
Date Applicant NEAREST DISTRICT NO GROUP TYPE PR CESSED BY
CROSS ST. ` /% CONST
L.a�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d
COMPENSATION INSURANCE DESCRIPTION I LOT NO. a BLOCK MAP HIGHWAY
NO OF BLD 65.
NO (CIRCLE) STATE MAJOR SECOND LOCAL
(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
SIZE OF LOT4 0 Y I EXISTING BLDG e d
I certify that in the performance of the work for which this „
permit is issued, I shall'not employ any person in any manner OWNER v
so as to become subject to the Workers' Compensation Laws UZ OCCUPANCY GROUP YE
MAIL �
Date Applicant ADDR 9 w
NOTICE TO APPLICANT' If, after making this Certificate of CIT NOL '� OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLI TION FOR EXIT HARDWARE
with comply with Such provisions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl,
. deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust - SAFETY PERMIT ❑ LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REq'D D PROVIDED D
SPACES
License Number Lie. Class
- � LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a d4:11 01-
FROM TO
licensed architect or a registered professional engineer' SIZE OF / NO OF / INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG .Xi STORIES SIGN URE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING ) .,r
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILD I GS f 311
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ACC f es_
License Law for the following reason (Section 7031 5, Busi- Jill? 27.70�
ness and Professions Code). NO PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED
P P YI 1 ITEMS
structure is not intended or offered for sale (Section "
7044,Business and Professions Code). Ti HAL 227 m 70
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING CHECK iy7�7-
I hereby affirm that there is a construction lending agency CHANGE .00
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). XrA
Lender's Name
PROPOSED MAX OCC
Lender's Address n �yf� /�},� r
�p(, Q
I certify that I have read this application and state that the p00AM
PERMIT FEE 0 1 8:40
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 pf this County to enter TOTAL. FEE ��
up thedop e bove entionry f ins p ction purposes
,9 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
r J
Signature of Permittee Date