HomeMy Public PortalAbout9073 HERMOSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 111-84) M ISCELLANEOUS APPLICATION
CE 675f�l
1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �IUII
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
ADORE 55
Certed copy is hereby furnished. BUILDING 9073 4E."06A �R.,
ADDRESS LOCALITY
O Certified copy is filed with the county building inspection LOCALITY
?r �./-'�� NEAREST
department. 1 GM��-+ �-I I � CROSS $T.
Date Applicant NEAREST 1_I A�1� Ave
' DISTRICT NO. GROUP TYPE P ESSEO BY
CROSS ST. FF�-lr/�rz ��'S/ {/ O (/ - 3 CONSIT'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL LOT o y
COMPENSATION INSURANCE DESCRIPTION NO. eLocK IDNww
NO! ICI CLS) STATE MAJOR SECOND LOCAL
jy NO. OF BLDGS.
(This section need not be completed If the work involved TRACT � {,.I NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (SI00) or less.) EyMe �^y USE of ,/�1{1r ' �/
SIZE OF LOT 6q k x1W j EXISTING BLDG. 1' 2
1 certify that in the performance of the work for which this � `,�-•�r o
permit is issued, 1 shall not employ any person in any manner OWNER 51" aEy v
so as to become subject to the Workers' Compensation Laws. MAIL '''']] �1e�ygp`pI '•1•� OCCUPANCY GROUP _3
AD DRE.. 40/3 WEIZI IWA •J , ij
Date Applicant w
TEL o_
NOTICE TO APPLICANT: If, after making this Certificate of CITY 11--�-t-') �„E �.1`IY No. L - 779 OCCUPANT LOAD y
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWAR E: z
Compensation provisions of the Labor Code, you must forth-
with comply with such provision Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION'S - 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 andQi t `
effectAg er.JL./ L PARKING REO•D PROVIDED
$PA CEs
License Number Lic. Class — LIMITED TIME USE
Contractor Date DATE PATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF p p No. of I IN SIGNATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 17— ^I�— STORIES SIGNATURE
eg
iness and Professions Cade).
I iTlilry FINAL APPROVAL „` q
PRESENT USE OF BUILDING t/ ) 1 LV (/
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS(
ON LOT ANO DSfi \(
1 hereby affirm that I am exempt from the Contractor's ry J}.,, t'�
License Law for the following reason (Section 7031.5, Busi- TzEU I�C� GAPf3C ��Y'Fs44ED•
ness and Professions Code): NO. PARKING -_itlr -.__i 1`i4= "I
F11, as owner of,the property, will do the work and the SPA CEs PROvIDED
structure is not intended or offered for sale (Section -
7044,Business and Professions Code). ;_T=q
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING =`_
I hereby affirm that there is a construction lending agency
UTI L ISI' 1--I4 . ..
for the performance of the work for which this permit is 1 fE1is
issued (Sec. 3097,Civ.C.). ,_
Lender's Name )'�}rid 154 m f S5
PROPOSED MAX. OCC. Ir rl( !C
Lender's Address
I certify that I have read this application and state that the PERMIT FEE 30.
above informatio is correct.I agree to comply with all County ISSUANCE FEE
ordinances and tate laws relating to building construction,
and hereby au rorae represent tives of this County to enter TOTAL FEE
upon the ab me ty6r}ed pr or inspection pr-- QI 41;1!-i E(1:11 5�1)�n7
IA SEE REVERSE FOR EXPLANATORY LANGUAGE
-7
Signature of Permittee Date