HomeMy Public PortalAbout10102 LA ROSA DR_Miscellaneous__ R'ORKERS'C061PENSATION DECLARATION a
CE 875171-94)
MISCELLANEOUS APPLICATION
CE 8]
I hereby'affirill 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUIL.1 No LOCALITY
ADDRESS
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. ! CROSS ST.
Date Applicant NEARESTDISTRICT NO. G OUP PE P CESSEO BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LGAL e
COMPENSATION INSURANCE DE.CRIPnory LOT NO. BLOCK MAP +GRwA
NOOF BLDGS.
(.IRC
Le) STATE MAJOR SECOND LOCAL
. No.
(This SCCtIOn need not be completed If the work involved TRACT NOW ON LOT USE ZONE BPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT EXISTING LOG. `L
1 certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation L- MAIL O D i OCCUPANCY GROUP o
ADDRESS
Date Applicant IViI
NOTICE TO APPLICANT: If, after making this Certificate of CITY NE OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLIC TION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION E] No Spec. Knowl.
deemed revoked.
El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices EJ
I hereby affirm that 1 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
effect. PARKING REOD PROVIDED
License Number Lie, Class 1 SPACES
LIMITED TIME USE
Contractor Date DATE DAT.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SiZE oP NO. OF INSPEcrow•s
acting in my professional capacity (Section 7051, Bus- EXlsn rvc BLOC. STORIES sl wru Rfi
iness and )
Professions Code .
-
PRESENT USE OF BUILDING FINAL APPROVAL
Lie.or Reg.No. Date W/ l
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 31)
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031.5. Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED T:+'+:
7l_I6:
structure is not intended or offered for sale (Section �I:I H� 146 - 50
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PRDrosfiD USE OF BUILDING -,
.IJ
1 hereby affirm that there is a construction lending agency .: 1(.;lti_ 1hi
for the performance of the work for which this permit is
issued(Sec. 3097,Civ. C.).
Lender's Name )it 1;''Ij—ijl EF 1 1 4
PROPOSED MAX. OCC. - -
Lender's Address ( C
PERMIT FEE l��LIJ 1. Ail 4•'11:i
1 certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County ISSUANCE FEE ('
ordinances and State laws relating to building construction,
and Iter + authorize representatives of this County to enter I TOTAL FEE �•
upole^
ve-mentioned opert r inspection ur oses
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee bite