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HomeMy Public PortalAbout9133 HERMOSA DR_Miscellaneous__ WOKKERS' at I'h' SATIONDECLARATION CE 875 MISCELLANEOUS APPLICATION �1 cF s75 (t t-sal Ll I hereby of cerA that I"have a .certificate of consent 'to self '' ` COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure;rox acertificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING ���o�R 6I ADDRSS 7 Y1 LOCALITY E Certified copy is filed with the county building inspection LOCALITY T NEAREST Lo�h � department. /(�'.. cRoss sr. 1• Date Applicant NEARESTj Q�,rr DISTRICT NO. RO CONST PRO E D BY CROSS ST. L ©g CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL — COMPENSATION INSURANCE DES CRIPTIory LOT No. BLocK =.�wa (CIRCLE) STATE MAJOR SEC ND LOCAL NO. OF BLDGS. US C (This SCC[IOn need n0( be COmpIC[Cd If the WO[k InVOIVCd TRACT NOW ON LOT VSE ZONE $PE CIP SPECIAL TIOf by the permit is for one hundred dollars ($100) or less.) USE of I certify that in the performance of the work for which this Slee OF LOT EXISTING BLDG. J! ¢---OIg —'O3`� o permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. MAL owrvEw MTP-4N OCCUPANCY GROUP //(� Ce ADDRESS ,$OM` Date Applicant w NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. - OCCUPANT LOAD z Exemption, you should become subject to the Workers' 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 NO Spec. Knowl. EJ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Q/ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT EJ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- rv0. of EXITS ness and Professions Code, and my license is in fullforce and effect. s Q. Ci L( PARKING SPACES REOD I� PROVIDED License Number Lic. Class - LIMITED TIME USE Contractor Date oA' E o,.TE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE of NO. of m cro R's acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. sroRres m ATURE iness and Professions Code). / PRESENT USE OF BUILDING RbSI(�GNTQ9L FINAL APPROVAL Lic.or Reg.No. Date Til HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I �.1_ Hv` aY 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 - pyJ I, as owner of the property, will do the work and the SPACES PROVIDED ] y7_is %structure is not intended or offered for sale (Section -i CITAL -23 3 o 65 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY .PROPOSED USE OF BUILDING I herebyaffirm that there is a construction lending I, '4112E g agency _}?�. for the performance of thework for whichthis permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address ,yi_(* 1 Flo, r.•_I5 PERMIT FEE I certify that I have read this application and state that the above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE -j G ��u on the entioJneed�property for inspection purposes. ` l� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date