HomeMy Public PortalAbout9174 FORTSON DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 .
• CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a,_ertificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800 ,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN wooREss
Certified copy is hereby furnished. BUILDING
ADDRESS I /�rIT Or:rc LOCALITY.
Certified copy is filed with the county building inspection �r NEAREST
department. - LOCALITY ''f CROSS ST. '
Date Applicant NEAREST "" ��, �`1 /�� DISTRICT NO. GR/��UP TYPE PROC D BY
CROSSLEGAL - •/f_ K�� CONST.' i
CERTIFICATE OF EXEMPTION FROM WORKERS' i V V
COMPENSATION INSURANCE
DESCRIPTION Lor NO. BLOCK MAP HIGHWAY �,
_ NO. (CIRCLE) STATE MAJOR SECO LOCAL, 0_
OF
USE TRACT • NOW ON LOT S
('1'1115 SOCtIOn need,not�be completed"if the•work involved q USE ZONE SPECIAL CONDITIONS. OU",
by the permit is for 'onb Hundred•dollars ($100_) or less.) . . [USE OF-- SI
_ SIZE OF LOT EXISTING BLDG.
I certify ��
that in the performance.of the work for whlch,this Q
permit is issued, I shall not employ any person in any manner OWNER' /n��v��c U
so as to become subject'to'the Workers' Compensation Laws. ADDRESS
J /y` OCCUPANCY;GROUP
�'7z.�� �• /���JI�ICL�G //Iri - • -'� N
MAIL
Date Applicant : - V
TE
NOTICE TO APPLICANT: If, after making this Certificate of CITY ,jQy/j �Qi�e/C NOI. 8�� �B7'r�� 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 provisions or this permit shall be, TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec.,Knowl. 0
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices
I hereby.affirm that I'am licensed under provisions of Chaptei SAFETY PERMIT ❑ (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 QQ l �/ �
effect. ' �4a «1 /OrI��T 4&e PARKING.
/� 11 SPACES REQ'D I I PROVIDED-
License Number Lic.Class F.Cf/9U° �619r1 meq, Tm PGrrrd/f /B�(�? �� 11
Q LIMITED TIME USE
Contractor. Date /�s—�lvi/f �/l �' DATE DATE
❑ FROM: TO'
I am exempt from the licensing requirements as I ani a. ve O_f'dL C
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in, my professional capacity (Section 7051, Bus-, EXISTING BLDG. STORIES S)GNATURE
mess and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING `
Lic.or Reg.No. Date
z
HOME OWNER-BUILDER DECLARATION No.of EXISTING BUILDINGS
ON LOT AND USE ,
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 - -
DI; as'owner of the,property, will do the work and the
structure is not intended' or offered for sale. (Section ; 4 6 3-8 A-
7044, Business and Professions Code).
PROPOSED USE OF BUILDING, V % - it 0:9;e 0 3 0
4 �J
' CONSTRUCTION LENDING AGENCY I 1,:• 8•Q 5.0.
I hereby affirm that 'there is a construction lending agency 4
"for the performance of the work for which this permit is I • . • $0.5 O v
issued(Sec. 3097,Civ.C.).
Lender's Name_ PROPOSED MAX. OCC. , 0•5 1•3 g 6
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; TOTAL FEE II�� •` ��))
and hereby authori're rep entatives of this County to enter Alv V
upo the above-m ntio roper y nor inspection'.purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofl, ittee Date