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Home My Public Portal About9914 DUFFY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS A P UCAT IO v I hereby affirit 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 certifiedcopy thereof(Sec. 3800,'Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS - ❑ Certified copy is hereby furnished. BUILDING n LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspectionNEAREST ' department, LocALITr CROSS ST. Date - Applicant L AA NEAREST - DISTR C T O'. G U TYPE PRO SSE. BY ' CROSS ST. 134 gi _ _ {,� ��, CONST / . CERTIFICATE OF EXEMPTION FROM WORKERS'. LEGAL //,� V i` V- COMPE'NSATION INSURANCE DESCRIPTION LOT No Z-4rJ BLocK MAP. HIGHWAY' } ' - NO. (CIRCLE) STATE MAJOR S OND LOCAL a NO. OF BLDGS. (This section need not be completed 'the work involved TRACT , �\ NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars-($100) or less.) USE'OF SIZE OF.LOT EXISTING BLDG. I certify that in the, performance of the work for which this O permit is issued,'I shall not employ any person in any mannerOWNERa;L !—' so*as to become subject to the Workers' Compensation Laws. MAIL ' OCCUPANCY GROUP W CL _3 ♦ _ ADDRESS �a..Yh Date Applicant TEL.$ zOCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY' NO. �+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 provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION C1 NO.Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L i (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. ` PARKING SPACES REq'D O PROVIDED License Number Lic.Class S` LIMITED TIME USE 17) Contractor— Date {`{\J oArE DATE - ...\ \VV`C� 'l�� L� "'\ FROM: TO.: ❑ I am exempt from the licensing requirements.,as.'I am a licensed architect or a registered'professional.engineer SIZE OF N OF INSPECTOR'S acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES S GNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date— NO. - NO.OF EXISTINGBUILDINGS - _ Z.7 7 2 HOME OWNER-BUILDER DECLARATION ory Lor AND use # o ®.o o $ 8, L hereby' affirm that I am,exempt from the Contractor's ppo:c�oq{ U License Law for the following reason. (Section 7031.5, Busi- ness and Professions Code): NO.:PARKING . SPACES PROVIDED ❑ 1, as owner of the property, will do the.work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING - CONSTRUCTION LENDING AGENCY I-hereby affirm that there is a construction lending agency 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 l I certify that I have read.this application and state that the above in mation.is correct. I agree to comply with all'County ISSUANCE FEE J or ' anc d Sta, 'aws relating to building construction,' TOTAL FEE a eb uthor ze ep a entatives I is County toe er osv. U a o n ' roper r o �po' SEE REVERSE F R EXPLANATORY LANGUAGE Signature f Perm ee Date WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self CE 875 (2-80)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED By CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL } DESCRIPTION LOT NO. BLOCK d COMPENSATION INSURANCE MAP (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. Ute' (CIRCLE) U (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.) u USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this LL permit is issued, I shall not employ any person in any manner OWNER } so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP `r ADDRESS Q Date Applicant LIC TEL. O NOTICE TO APPLICANT: If, after making this Certificate of clrY NO. OCCUPANT LOAD LL Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- W with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. 1:1 ~ deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and --- PARKING effect. SPACES REO'D D PROVIDED License Number Lie.Class LIMITED TIME USE Contractor Date o A r E D A T E 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. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie_or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE .. I hereby affirm that I am exempt from the Contractor's a License Law for the following reason (Section 7031.5, Busi- ness and PIOfe5510n5 Code): SPACES PROVIDED 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 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 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 Sta a laws relating to building construction, and hereby author ze representatives of this County to enter TOTAL FEE u n the above- nt�one ,property for juspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature bf Permittee Date