HomeMy Public PortalAbout9014 HERMOSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
' ..4 • CE 875 (2-80) MISCELLANEOUS APPLICATION
I hereby affirm ithat 1 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
/ AD REas
❑ Certified copy is hereby furnished. BuILDINc Q /���MOSA
ADORES. LOCALITY
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY �T /rr/ c`./� ./ CROSS ST. _a�,•„��,Z�j�
Date Applicant NEAREST go sCr 1—c CROSS
L-✓� DISTRICT N OUP TYPE PR $SED BY
CROSS $T. _ coN$T.
CERTIFICATE OF EXEMPTION FROM WOR KER5' LEcaL
COMPENSATION INSURANCE DEsc RIPnoN LOT rvo. BLocK MA,
NO. OF BLp G.. ,GRWA }
ICIwCIeI STATE MAJO sE ONO LOC a
O
(This section need not be completed if the Work involved TRACT �.® NOW ON LOT USE ZONE SP ECIwL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) S )/ ^ 1115 USE OF
SIZE OF LOT EXISTING BLDG.
1 certify that in the performance of the work for which this _ A -r- ��'� 0permit is issued, I shall not employ any persona in any manner OWNER MR S• T QA cl OCCUPANCY GROUP
GKs of �f l L)
so as to become subject to the Workers' Compensation Laws. MAIL
ADDRESS SA ME a
Date Applicant (� // N
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL
,WS 76 rtp 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 N ❑
deemed revoked. o Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION W
Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS a
9 (commencing with.Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect SPACES REO'. = PRO..
License Number Lie.Class Q JG
LIMITED TIME USE
Contractor Date S i2- ` �' / .v - / . Dare Dare
FROM: TO:
❑ I am exempt from. the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF IrvsPE ero R's
acting in my professional capacity (Section 7051; Bus- EXISTING BLDG. STORIES smrvwru
iness and Professions Code). PRESENT USE OF BUILDING — FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO, OF EXISTING BUILDINGS
ON LOT AND USE 5
1 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
❑ I, as owner of the property. will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING l '
.8421A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency se e e e 3 Q
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). 2,• • 8 0.5 0
Lender's Name
PROPOSED MAX. OCC.
Lender's Address t °PERMIT FEE ° ° 8 0,510chi
-
I certify that I have read this application and state that the 121 ,7.-• 8 2
above information is correct. I agree to comply with all County ISSUANCE FEE f® -
ordinances and State laws relating to building construction, TOTAL FEE
a ereby authorize representatives of this County to enter ,
o he abo -nentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/�— �7''Uo�—•
Signature of mittee Date