HomeMy Public PortalAbout8908 HERMOSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 ���
CE 875(1,-84) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LJ
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO F I LL I N BC ILDING /J'
ADDRESS V4(4
Certified copy is hereby furnished. BUILDING '
,/' LOCALITY
ADII ESS • 1 /\
F1 Certified copy is filed with the county building inspection LOCALITY A
NEREST
department. .��. CR
0S ST.
Date Applicant NEAREST DISTRICT NQQQ��� OUP TYPE PR SCO BY
CROS
S ST. �r1l�.11� /I\/ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL vo
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK ,G a,ww
LOGS. NO. R
tCl CL@I STATE MAJOR sECONO OCAL
(This section need not be completed if the work involved TRACT ]NO OFNOW ONBLOT USE ZONE SPECIALCONDITIONS
by the permit is for one hundred dollars ($100) or less.) E F
I certify that in the performance of the work for which this SIZE of LOT Us O Ne BLD G.
OSOo
permit is issued, I shall not employ any person in any manner OWNEREh(� I And rew 61I LLV
so as to become subject to the Workers' Compensation Laws. (� 1y`�-p y��� !� OCCUPANCY GROUP; Q�� o
NOOFES DCJ �- 1 1Vr1, l�cl� 3r > _ \ V
Date Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of CITY .f71 '� C, t+ rvo` ��5'l7s'7 3 \OCCUPANT LOAD
Exemption, you should become subject to the Workers' qpp LICA N 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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI (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 �-� O O Veil I�iL ht
effect. PARKING REO•D � PROVIDE.
• SPACES
License Number Lie. Class
LIMITED TIME USE
Contractor Date oATC DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
E
acting in my professional capacity (Section 705 1, Bus- EXISTING BLDG. STORIES SI NATUR?i
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Dale
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 G L /,
I, as owner of the property, will do the work and the SPACES PROVIDED Y Z U 3µ5'A
structure is not intended or offered for sale (Section - # o •'s e
7044,Business and Professions Code). -
80
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING - ' - = I e - 80.50
I hereby affirm that there is a construction lending agency r
o e e
for the performance of the work for which this permit is -
issued(Sec. 3097,Civ.C.).
Lender's Name _ ,��\ Q`I•'I 44^$7�
PROPOSED MAX. OCC. .\ \
Lender's Address I - - t
I certify that I have read this application and state that the PERMIT FEE G r
above information is correct.I agree to comply with all County ISSUANCE FEE 5-0 �{
ordinances and State laws relating to building construction, CIA
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date