HomeMy Public PortalAbout9102 HERMOSA DR_Miscellaneous__ ,WORKERS'COMPENSATION DECLARATION
CE 875 (t 1-84) MISCELLANEOUS APPLICATION
CE 875 �I
I hereby of COTt that IfWo a certificate of consent Insurance,
nc self COUNTY OF LOS ANGELES - BUILDING AND SAFETY DIVISION
insure','or a'cert�cate of Workers''Compensation Insurance,or '
a certified copy thereof(Sec. 3800,Lab.C.). -
Policy No. Company FOR APPLICANT TO FI LL IN
❑ Certified copy is hereby furnished. BUILDING LO CALITr /e /�, ye /+ �]
CA
AD OR E55 (6 - /� L•� _ 1 l 1. /
❑ Certified copy is filed with the county building inspection LOCALITY ./ PL-r, NEAREST a�
department. �id / L- I, C� CROSS ST. ,+
Date Applicant NEAREST TRICT NO TYP PR SE BY
CROSS ST. `� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL -
COMPENSATION INSURANCE DE5CRIPT10N LOT NO. BLocKIOHWA
moP (clp cLa) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed If the WO[k involved TRpLT � NOW ON LOT - USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) _ USE of
SIZE OF LOT EXISTING BLDG. a
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 JFJZ /V d /f y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
D J'J� O ` U
Date ADDRESS
Applicant LLI
NOTICE TO APPLICANT: If, after making this Certificate of CITY r-rx1/I(_6 Clz� rT+ot bf).1 / 460
/8b OCCUPANT LOAD °-
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
z
Compensation provisions of the Labor Code, you must forth- ❑
with comply With such provisions or this permit shall be .TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. -
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ -(usT 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
effect. /B)LL- 8 f4 e2 P GGL: PARKING
SPACES RED = PROVIDED
License Number Lic. Class N421 0 Jam(. Cr 1 Z, 0
LIMITED TIME USE
Contractor Date IffI U (-- I PJ to, rdE i1apt"zo" DArE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. of FROM: TO: INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- ExlsnrvG BLDG,G, ( " Q STOR IES / SIGNATURE
mess and Professions Code). FINAL APPROVAL
Llc.or Reg.N0,-Date PRESENT USE OF BVILDING /v 1�
HOME OWNER-BUILDER DECLARATION NO, OF EXISTING BUILDINGS .. J
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor's 630
7License,Law for the following reason (Section 7031.5, Busi-
and Professions Code): NO. PARKING10
1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section 33217 _-O
l 7044,Business and Professions Code).
30
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY - - y
I hereby affirm that there is a construction lending agency AUT,
for the performance of the work for which this permit is S:rO! DA
issued(See.3097,Civ. C.).
Lender's Name - 1 ITEMS
PROPOSED MAX. OCC.
Lender's Address TOTAL '80 50
I
I certify that I have read this application and state that the PERMIT FEE. !:HECK
above information is correct I agree to comply with all County ISSJANCE'FEE
ordinances and State laws relating to building construction, L.. CHANGE Oct,
and hereb thorize r resentative> of this County to enter TOTAL FEE J -
upon abov -men o ed property for inspectio purposes. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
01300 3101 11/17/5-9
Signa Pennit[e D e O6u 1 AN 9:1.5