Loading...
HomeMy Public PortalAbout9843 ESTRELLA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 675 (11 841 44 MISCELLANEOUS APPLICATION {� CE LI I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELEQ�' BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). _ `` Policy No. Company FOR APPLICANT TO FILL IN - ��` BUILDING p/1 ADDRESS d i ❑ Certified copy is hereby furnished. BUILDING (} l I Lee.."'A9 Certified copy is filed with the county building inspection LOCALITY C EASIEST department. L I CROSS ST. DDRESS ( Date Applicant NEAREST / "A - DISTRICT NO. G uPITYPE CONST. CESSED BY CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALo COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK I�HWA (C FLE) STATE MAJOR SECOND LOCAL NO. OF BLO GS. (This section need not be completed if the work involved TRACT 'NOW ON LOT USE 20NE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or'less.) USE TI I certify that in the perfoimance of the work for which this SIZE OF LOT USE OF BLDG. d permit is issued, I shall not employ any person in any manner owNER G/�yhN so �tld ,���k- DC E3 So as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP 3 CD CD ADDRESS Date - Applicant MAIL �j[�? L S /L�p NOTICE TO APPLICANT: If, after making this Certificate of CITY �f( 7 NO` D�B z7„-f --35-3OCCUPANT LOAD 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 E] GEOLOGY INSPECTION ❑ No Spec. Know[. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO, OF EXITS ness and Professions Code,and my license is in hull force and _ SPACCESES effect. Pr`oo ?K PAREG•D PROVIDED License Number Lie. Class C 7�—27 Z LIMITED TIME USE Contractor Date oATE DATE El1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE of NO. OF I N PEC vRE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code).. 'A L. PRESENT U EOF BUILDING FINAL APPROVAL r.3r `J Lie. or Reg.No. Date <�t ,,✓� `�,, y J 01 HOME OWNER-BUILDER DECLARATION rvo. of ExIsn NG BUILDINGS yJG(0/v,I�- Jilt /Z, lo ON LOT AND USE /�j iii'' =T I hereby affirm that I am exempt from the Contractor's _ .- License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED M” ©1, as owner of the property, will do the work and the t^4 structure is not intended or offered for sale (Section TI-ITFi1 234 e 45, 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I hereby affirm that there is a constriction 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 (/ 5"4^ PERMIT FEE JJ+i O �� S 111 -J°ii 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 -2 �40 ordinances and State laws relating to building construction, .r �' '/L� and hereby authorize repres r�olives of this County to enter TOTAL FEE02& up nbove- n d o,jrer[y for inspection purposes. L5--- SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur f Permittee Date