HomeMy Public PortalAbout8731 HERMOSA DR_Miscellaneous__ tCE875 (11-84)
\�ORKERS'COMPENSATIONDECLARATION a MISCELLANEOUS APPLICATION
CE 8]
.I hereby affirm that I have a certificate or 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. CompanyBUILDING
FOR APPLICANT TO FI LL IN ADDRESS
Certified copy is hereby furnished. a uo ING r _
AV. t .� (7�J� 1 LOCALITY �L
Certified copy is filed with the county building inspection L AurY + NEAREST
department. CR"S
ST. CC
Date Applicant NEAREST DISTRICT NO. G UP TYPE PROCES� BY
CROSS ST. ; ,` o CONST. J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL GJ
COMPENSATION INSURANCE DESCRIPTION LOT No. BLo cK IGMwn
_ NOP (CIRCLE) STATE MAJOR SECOND LOCAL
/�J/�2Q NO. OF SLOGS.
(This Section need not be completed if the work involved T ACT d5 w ON LOT Z USE ZONE SPECIAL CO NOIT IO N5
by the permit is for one hundred dollars ($I00) or less.) -' y
usE ofP.
ZE OF LOT XIST ING BLDG. 4ffl d
I certify that in the performance of the work for which this aIf r
permit is issued, I shall not employ any person in any manner NER - y
so as to become subject to the Workers' Compensation Laws. IL I .�,',OCCUPANCY GROUP,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Y `� o��l� '�''-S U Z V OCCUPANT LOAD' y
Exemption, you should become subject to the Workers' z
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 GEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ - No Spec. Know[.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
I hereby affirm-that I am licensed under provisions of Chapter I )
9 (commencing with Section 7000) of Division 3 of the Bu 1- SAFETY PERMIT ❑ (LIST ITEMS BELDwNO. OF EXITS
ness and Professions Code, and my license is in full force and _
effect. G PARKIN - —
SPACES REO'D � PROVIDED CJ
License Number Lic. Class «' `�"
LIMITED TIME USE
Contractor Date (y` � DATPATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineerslzE OF rvo. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- XISn-G BLO G. STORIES sl ATURE
iness and Professions Code). - FINAL APPROVAL
PRESENT USE OF BUILDING Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS P 28A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's - t{ a ° • • 30
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING .I * 80,50
.
I, as owner of the property, will do the work and the SPACES PROVIDED ., ., \�, .�l e • •_ �
structure is not intended or offered for sale (Section _. -j? �,� ;ti J.?• a
7044,Business and Professions Code).
`a.. `� `' 053.1 .88
PROPOSED USE OF BUILDING t S
CONSTRUCTION LENDING AGENCY `
I hereby affirm that there is a construction lending agency ) '\\''� •x.�.,a� c. ' y, ^
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). ,t l\ , Y -,c—
Lender's
c--Lender's Name "� I'• `., "� ,'�'.
PROPOSED MAX. OCC.
Lender's Address - +..\J ���',' '� `.'�
PERMIT FEE -
I certify that I have read this application and state that the h \,
above information is correct I agree to comply with all County IssuwrveE FEE ( "s
ordinances a Id State laws relating to building construct n,
and
he
authorize representatives of this County to ent r TOTAL FEE60
upon the bbve-mentiongd pr)pr-cLy' or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si v Lure of"Permittee Date