HomeMy Public PortalAbout9165 HERMOSA DR_Miscellaneous__ WORKERS'}"OMPE 'SATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
I '� CE 875(11*84)
I hereby affirm/J,(yat I have a certificate of consent to self
I=re, v a ce}tlfn* to of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES +BUILLING AND SAFETY DIVISION
a certifielcopy thereof(Sec. 3800,Lab.C.). _
BUILDING
Policy N_.; Company FOR APP LICANT TO F I LL I N ♦., ,
❑ DORESAD DRESS
CertLed copy is hereby furnished. ANG p LIQ«
p DP S / LOCALITY
Certified copy is filed with the county building inspectionLOCALITYNEARESTIF
department. CROSS ST. i(h Gtn r~
Date Applicant NEAREST / I _ DISTRICT NO. GROUP TYPE CE-SE:
BY
Cpp55 ST. �-"C(� �O� CONST. C�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1p
COMPENSATION INSURANCE DESCRIPTI
ON I Lor N J ((7 BLOCRI�Nw.
_ rvo• (u cLel STATE MAJOR SECOND LOCAL
//
(This $eC[IOn need not be completed if the work involved TRACT �90I�+ NO. OF BLDGS.NOW ON LOT [� USE 20NE BPECIpL CONOIT IONS
by the permit is for one hundred dollars ($100) or less.) USE
0 DP '
SIZE OF LOT I�+D EXISTING BLDG.
I certify that in the performance of the work for which this V ✓ -
permit is issued, I shall not employ any person in any manner OWNERg-yyl-per'
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP DEE ADDRESS q/6s [,V(,�Q./ '1 U
Date Applicant �J� 1 uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY 6 rT-. 9II$ 2A�j- �. f OCCUPANT LOAD
Exemption, you should become subject to the Workers' ?
Compensation provisions of the Labor Code, you must forth- AP CATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be
deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION C] No Spec. Knowl. El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter swwfirr PERMIT ❑ (usr 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. ¢� .�� PARKING
SPACER Rfip'D DP--V,-Mo
O
License Number Lie. Class �7 .SA
LIMITED TIME USE
Contractor Date �y9y S-/9 tea /. a i5 DATPATE
I am exempt from the licensing requirements as I am a TO
licensed architect or a registered professional engineer SIZE of NO. OF m e -T R's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES G uRE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING (f(�
Lie.or Reg. No. Date
:I
HOME OWNER-BUILDER DECLARATION NO. OF E%ISTING BUILDINGS
y
ON LOT AND USE i all T -j
I hereby affirm that I am exempt from the Contractor's �h
License Law for the following reason (Section 7031.5, Busi- ��