HomeMy Public PortalAbout9805 HOWLAND DR_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION
CE 875 (280) MISCELLANEOUS APPLICATION {�
CE 875 u
I hereby,affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES, BUILDING AND SAFETY DIVISION
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 BUDO RILDE55 ING
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Certified copy is hereby furnished. BUILDINGO Ae LOCALITY
❑ ADDRESS
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY m �� CR055 ST.
Date Applicant NEAREST DISTRICT NO. GR VP TYPE PROCESSED BY
CROSS ST. (/L 'v/ rz, J r j CONS
CERTIFICATE OF EXEMPTION FROM WORKERS'
LEGAL
COMPENSATION INSURANCE DEsc RlPn ory Lor rvo. eLocX
MwP (CIwC LEI STATE MAJOR SECOND LOCAL a
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ION E SPECIAL CONDITIONS O
by the permit is for one hundred dollars (5100) or less.) EXE of
SIZE OF LOT IUSEXISTING BLDG. /�
I certify that i, the performance of the work for which this OWNER _ O
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. MAIL �/J� (� r� OCCUPANCY GROUP W
ADDR E55 / �OJ� CI a
Date Applicant to
NOTICE TO APPLICANT: If, after making this Certificate of CITY > xoL 6 — 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
deemed revoked. ❑ Cl No Spec. KnoWl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic DEVICES ❑
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOWI NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PwwXlrve.
effect. SPACES REO'D � PROVIDED D
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATC DATE
❑ I am exempt from the licensing requirements as I am a
I icensed architect Or a registered professional engineer SIZE OF rvo. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
mess and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
NO. OF EXISTING BUILDINGS / Y• ` GvS� -I /�-Sf/ (� '"/`S
HOME OWNER-BUILDER DECLARATION ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5. Busi-
ness and Professions Code): SPA PES PRO '^ O
❑ SPACES PROVIDED A6 ev , 6--
structure
1, as owner of the property, will do the work and the • `tt��)••«
structure is not intended gr offered for sale (Section 1 Q 1 4•_8 2
7044, Business and Professions Code). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is /--
issued (Sec. 3097,Civ.C.).
Lender's Name v
PROPOSED MAX. OCC. L��..a, /^/
Lender's Address PERMIT FEE �. �� �,' P'- ,1 /
I certify that 1 have read this application and state that the /
6600 III r
above information is correct.I agree to comply with all County ISSUANCE FEE ` �y ✓ —V
ordinances and State laws relating to building construction, TOTAL FEE r/ CL Tc.."
and hereby authorize representatives of this County to enter t Z
opo the eb ve-mentioned prope y inspection purposes. SEE REVERSE FO EXPLANATORY LANGUAGE
tj
I nature of Permittee — Date