HomeMy Public PortalAbout9149 HERMOSA DR_Miscellaneous__ WORKER3'COMPENSATION DECLARATION CE 8754 MISS LLANEOUSAPPLICATION
CE 875(11-84)
I hereby affirm that I have certificate of consent to ser COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. Q.
Policy No. Company FOR APP L ICANT TO F I LL IN BUILDING y/�
ADDRESS / --
Certified copy is hereby furnished. BUILDING q
Arub
OOR ESS 17 LOCALITY
Certified copy is filed with the county building inspection LOCALITY " f C' CNEAR EST
department. �EM p L C(Ty CROSS ST.
Date Applicant NEAREST J.� DISTRICT NO. GROUP TYPE ESSED BY
CROSS ST. N L-FlS "rungs ENCINrl CONST.
CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL '
COMPENSATION INSURANCE DESCRIPTION LOT No 3.4 r7ewcK A .GA
n0.� (CI Cle) STATE MAJOR SECOND LOCAL
/� .
(THIS section need not be completed If the WOIk involved TRACT 5`(O � NOOF BLOGS..NOW ON LOT 1 USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF � (
SIZE OF LOT ,5•o X 150 EXISTING BLDG.
I certify that in the performance of,the work for which this
permit is issued, I shall'not employ any person in any mannerOWNER U L y
so as to become subject to the Workers' Compensation Laws. b rTOV A I OCCUPANCY GROUP o
MAIL
Date Applicant ADDR Ess p T� w
NOTICE TO APPLICANT: If, after making this Certificate of CITYTl7-)Pj.e C NOL 8 d 8 — OCCUPANT LOAD a
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: —
with comply with such provisions or this permit shall be I El
revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 and I%
effect. [ 1'{
O 13 C PARKING
SPACES REO'D D PROVIDED D
License Number Lic. Class E LIMITED TIME USE
Contractor Date— DATE DATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFSO. F Iry G CTOR's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 11q9
roRIEs sIruRE
iness and Professions Code). I
I FINAL APPROVAL /�\ U
PRESENT USE OF BUILDING
Lie.or Reg.No. Date
HOMEOWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS '--' '==''•"
ON LOT AND USE 1 t T�Pi.
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- -(fI AL 2__34 ,4-'e
ness and Professions Code): NO. PARKING
7 11I, as owner of the property, will do the work and the SPA ces PROVIDED C ED ('' _HE(_K _ * Y=i
structure is not intended or offered for sale (Section �. �iFt'�t I_I_
7044,Business and Professions Code). '
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency !!r!L!L!'�!LfLIZ IiiY
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. Dec.
Lender's Address D O
I certify that I have read this application and state that the PERMIT FEE �L
above information is correct.I 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 a3 LJL�
upon the above-mentioned property for inspection purposes.
�I SEE REVERSE FOR EXPLANATORY LANGUAGE
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uye,p{Frlp M U Date