HomeMy Public PortalAbout9860 HOWLAND DR_Miscellaneous__ - WORKERS'COMPENSATION DECLARATION 76M444
,��-� CE 875 (2-80) MISCELLANEOUS APPLICATION ylLfll
1 heIeby f[�that.1 have certificate of consent to self
insure,Cn a 2erti ficate of Workers'
rs'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
_
a certified copy thereof(Sec. 3800,Lab.C.)
Policy Ro. Company FOR APPLICANT TO FILL IN BUILDING
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Certified copy is hereby furnished. BUILDING
ADDRESS 4? qV/O /yDW6f V
D LOCALITY
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Certified copy is filed with the county building inspection ��r r� NEAREST
department. LOCALITY 'TEM 1'L(.� C�K 4'O
K,1 L-iT 7 / .2 CROSS
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DatC - ApplicantNEAREST n r/ DIST`e-C Tjjjj''''11110. U$$$ TYPE PROCE ED BY
CROSS ST, f}¢ND J D CONS
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CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL p C7
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COMPENSATION INSURANCE ESCRIPTION LOT NO. BLOCK MAP .mRwE y
v (CIRCLE) STATE MAJOR SEGO D LOCAL a
�y NO. OF BLOCS.
(This section need not be completed if the work involved TRACT /✓J NOW ON LOT USE ONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars (SI00) or less.) U
//''y�� ✓ Y^( USE OF /
SIZE OF LOT �`l ♦ / / - [ � EXISTING BLDG. 2
1 certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner ow NER tTkykt_ eflc/✓i� IV /�C—+�/ �G/�✓ 7 U
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS �'rCN 4'�i! a
Datc Applicant p to
NOTICE TO APPLICANT: If, after making this Certificate of CITv7-E��F C', eio� O f �� OCCUPANT LOAD ?
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with SUCK prUVI510n5 or this pElmll Shag be
deemed revoked. TRAILER USE C] GEOLOGY INSPECTION C] oP
NSpec. Knowl. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW)
9 (commencing with Section 7000)d of Division 3 of the Busi-
nessand Professions Code, and license is in full force andqD1D/ SPACES PARKING.
effect. REO'D � PROVIDED
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License Number Lic.Class T
G 7 . p 04 mss, S"S' DpTLIMITED TIME USE
Contractor Date 91 DATE
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF ND- OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING G
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF Ex ISTING BUILDINGS
ON LOT AND USE
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
SPACES PROVIDED
I, as owner of the property. will the work.and the ]/1 7,,Q A
structure is not intended or offerere d for sale (Section
7044, Business and Professions Code). # e e e e 3 0
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY . ° ° 8 Q 5 0 -
1 hereby affirm that there is a construction lending agency - • ° • 8 Q 5 Q
for the performance of the work for which this permit is
issued (Sec. 3097.Civ.CJ.
Lender's Name O 7. 1 S t 8 7
PROPOSED MAX. Dec. i
Lender's Address PERMIT FEE
I certify that 1 have read this application and state that the t
above information is correct. I agree to comply with all County ISSUANCE FEE /10
V
ordinances and State laws relating to building-construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purpu SEE REVERSE POR EXPLANATORY LANGUAGE
7-1-r 9
natur of Fermittee Date