HomeMy Public PortalAbout9822 HALLWOOD DR_Miscellaneous__ WORKERS:COMPENSATION DECLARATION
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CE 875 (11-84) M 8 SC E L LA N E®U S APPLICATION
I hersby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a mjificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). BUILDZ,ioo fl n
NG
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS
U V
ADDRESS
Certified copy is hereby furnished. BUILDING 9 j� AZL(�o o 0
ADDRESS aC LOCALITY
El Certified copy is filed with the county building inspection LOCALITYNEAREST
f
department. �EM�Cr� �` T
CROSS ST.
Date Applicant NEAREST /// ' /I �J ` DISTRICT G UP TYPE PROCES D BY
CROSS ST. CO NST.J/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. 1p BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECON LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT �(� NOW ON LOT US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) �/ n �(/f� _
SIZE OF LOT�6•J �c �`� IRT �L Wv�0/�
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER b8457/QT,oF"0L/ AX1 TIVA 6W646
so as to become subject to the Workers' Compensation Laws. MAIL `\OCCUPANCY GROUP-
/7 '. .... \ t-,j' /• O
ADDRESS 0'�-? QLLGlJ00 :• . .,�,_ .�
Date Applicant /J / f w
NOTICE TO APPLICANT: If, after making this Certificate of CITY /,�i/�l� CST y no�I11 Z�b U6� OCCUPANT LOAD N
Exemption, you should become subject .to the Workers'
Compensation provisions of the-Labor Code, you-must forth- APPLICATION FOR EXIT HARDWARE:
with comply:With such provisions or this permit shall be TRAILER USE -
deemed revoked. E] GEO GY INSPECTION E] No Spec. Knovvl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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 ACTE� r � � /y�/f/J�
effect. /9n�-�T f �I PARKING
SPACES
� REQ'D D PROVIDED D
License Number Lie. Class abCK S � AFT11- M 6ARf4rf? 9d�F
LIMITED TIME USE
Contractor Date /� ZrD DATE DATE
I ain exempt from the licensing requirements as I am a 4111 120OAl I FROM: TO:
licensed architect or a registered professional engineer SIZE OF o. of INSP cTOR S '
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S NATURE
iness and Professions Code). FINAL APPROVAL IV
PRESENT USE OF BUILDING
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS D 9 b Q 3 A
ON LOT AND USE Z
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
El I, as owner of the property, will do the work and the SPACES PROVIDED * \` t .1— o80,
� rJ()
structure is not intended or offered for sale (Section -�)' • .'�` _\ ' '` \\ _
7044,Business and Professions Code). 0-0.0
`8 0,'50
,'5 0.0
PROPOSED USE OF BUILDING •�, ,F \
CONSTRUCTION LENDING AGENCY — _y p 5 l 2 8'8
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
I certify that I have read this application and state that the PERMIT FEE
70,04)
above information is correct.I agree to comply with all County ISSUANCE FEE L
ordinance nd State laws ting to building construction,
and h uthorize r rese ativ of this County to enter TOTAL FEE V
o e-mentio
upo th pe inspection pulp ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee V ate