HomeMy Public PortalAbout9916 HOWLAND DR_Miscellaneous__ 76MaaaWORKERS' COMPENSATIONDECLARATION 20-0063D.PW12/90 MISCELLANEOUS XPPLldTnO�N
1. hereby affirm that I .have a certificate of conscnt.LAO self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a'certificate of Workers' Compensati& Insurance, or '
a.certified copy thereof (Sec. 38001 Labi C.)'
Policy No. Company FOR APPLICANT TO'FILL IN BUILDING /
,. �. _ .- DDRESS G
• '' - • - BUILDING ADDRESS .. .– A
- -
❑, Certified copy is hereby furnished., C ;q 4.vlL A-A,10 LOCALITY M
❑ Certified copy is filed with the county building inspection CITY.-�" (/Iy zIP /�"J� /�'�i�]
department:• / �7�7 LE \✓� / / • o v NEARESTTr
_ CROSS ST. _
Date Applicant SIZE OF LOT NO'OF BLDGS.NOW ON LOT" DISTRICT N Gr TYPE PROCESS BY '
'l. CONST.
tCERTIFICATE OF EXEMPTION iFRQM WORKERS' TRACT BLOCK Lor No. >;
COMPENSATION INSURANCE MAP HIGHWAY
— Jt NO. (CIRCLE) STATE'M AJOR SECOND CAL
(This'section need not•be-'completed if the work involved ASSESSOR MAP BOOK', ' PAGE 'PA RCEG - '
by the permit is.for one hundred dollars ($100) or less.) USEZONE SPECIAL CONDITIONS;.
U.
11
I certify that in the r OWNER TEL NO;
performance of,the work for which this Jµ�-4�� 919-a�'-31 z�, O
ermit is issued I shall not employ any person in any manner - - . - _
so as to become subject to the Workers' Compensation Laws. ADDRESS
n CY GROUP �j
` -q1 GuCAN�U� OCCUPAN � W
so
Date' Applicant CITY _ zla ��.yy -7_ -
NOTICE TO APPLICANT:,'If after' making this Certificate OCCUPANT LOAD
of.Exemption' you!should' become subject to the Workers' APPLICATION FOR e
Compensation provision's of the'Libor Cod'e.;you most forthwith EXIT HARDWARE:
comply with such, provisions or this •permit;sliall. be'deemed TRAILER USE❑ GEOLOGY INSPECTION❑ NO Spec.KnOWi. ❑
revoked.
' •` OCCUPANCY INSPECTION❑-- - - - Panic Devices •❑.
LICENSED CONTRACTORS DECLARATION
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 Business. NO.OF EXITS'
and Professions Code,and`my license is in full force-and effect.
- PARKING• REWD � PROVIDED O
License Number. Lic.-Class ' t SPACES
Contractor Date LIMITED TIME, USE -
. DATE DATE
El am exempt from'-the Iicenstng requirements as I am a FROM: TO:
licensed architect or a registered professional engineer
acting in,my professional capacity (Section 7051,Business SIZE OF - NO.OF ` INSPECT R's
and Professions Code). EXISTING BLDG. STORIES ` SIG
PRESENT USE OF BUILDING FINAL APPROVAL /w!�2�
Lic.'or Reg: No. _ . . .. _ Date lYY
HOME,OWNER-BUILDER DECLARATION NO.OF EXISTING 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, Business and
Professions Code): NO.PARKING Q1
❑ I, as SPACES PROVIDED owner of the property, will do-the work and the JL
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING
Business and Professions Code). 747 L �a
70
CONSTRUCTION LENDING AGENCY 1 ITEMS.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued TOTAL 242 70
(Sec. 3097, Civ. C.). •-_ - �. .- - 'PROPOSED MAX'.'.00C
' q—pp (CAN_T�(PRINT),
� TEL XNO. CHECK
HLR-i 242.70
Lender's
[2a71Lender's Name
. .
Lender's Address ADDRESS __ �/ CHANGE a40_.
I certify that 1 have read this application and state that the 1&-0g0tX b-'-1U_ �b L&(1t
above information is correct. I agree to comply with all County PERMIT FEE _ �-+ C c
ordinances and State laws relating to building construction,and d "' - 0000-0001 5/15/'93
hereby authorize representatives of this County to enter upon ISSUANCE FEE a C c
the above-mentioned property for inspection purposes. O� 3� - -- - 6454 - 1 PM •-ta 12
TOTAL FEE _:&2. 76
. D
.'
SEE REVERSE FOR EXPLANATORY LANGUAGE '
Signature of Per} ittee Date