HomeMy Public PortalAbout11002 GREEN TREE LN_Miscellaneous__ WORKERS'COMP,;.NSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
I hereby affirm tCE 875 (11-84)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. Company FOR APPLICANT TO FILL IN BUILDING / DO01
�+ ADDRESS
Certified copy is hereby furnished. ...Bess O Z ��� �� LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. cRoss sr.
Date Applicant NEAREST ' c DIST� GCT NO. U TYPE PROCESSED BY
CROSS ST. ` •+ n/ �'� \ /(v _ CONST
—
06
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ` o
COMPENSATION INSURANCE DESCRIPTION LOT NO. 3 BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SEC ND LOCAL
NO. OF BLDGS.
(This SBCtIOn need not be completed if the Work involved TRACT NOW ON LOT US/E ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF pl��
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. /� o
permit is issued, I shall not employ any person in any manner OWNER , ='
so as to become subject to the Workers' Compensation Laws. /MAIL ) 61 4r,111
/� 1 (y�I y�// OCCUPANCY GROUP,�t,• ��? Iz
ADDRESS II OO V/�4im� h !✓•4 X- ,:� t`� ` •1� E3
Date Applicant LSI-,
NOTICE TO APPLICANT: If, after making this Certificate of clrY C No� �Q60 4 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLI ATION 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 ❑ No Spec. Knowl.
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 full force and
effect. PARKING REQ'D I PROVIDED
SPACES
License Number Lie. Class _ o/ LIMITED TIME USE
Contractor Date �— 'L DI/ 4_ DATE DATE
El I am exempt from the licensing requirements as I am a
FROM:
licensed architect oI a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES VGNATUF3E
iness and Professions Code).
PRESENT USE OF BUILDING W/��G. C— FINAL APPROVAL
Lie.or Reg.No. Date ' I1 .49
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS z 979.A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's # o 0 0 0 3 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING I ° ° 8 (15.0
I, as owner of theproperty, will do the work and the SPACES PROVIDED •%
+�_t
structure is not intended or offered for sale (Section _ :- o-0, o 8 (1 ,500
7044,Business and Professions Code).
' PROPOSED USE OF BUILDING �. I,,+�`� { O'�w°$
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 `
PROP-OSED..MAX. OCC. '-
Lender's Address
PERMIT FEE t00
•
I certify that I have read this application and state that the -70Q
above information is correct..1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and Hereby authorize representatives of this C unty to enter TOTAL FEE KO
upon the above-men 'on d p p for insp ct' n purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of P ittee Da