HomeMy Public PortalAbout10134 LA ROSA DR_Miscellaneous__ 1VORKERS'COAIPENSATION DECLARATION
CE 875(11-Bal M ISCELLANEOUS APPLICATION
CE 875 n
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING, AND'SAFETY DIVISION �ILJII
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). a
Policy No. Company FOR APP LICANT TO F I LL I N BUILDING
ADD.ESS
.NG u+
Certified copy is hereby furnished. BU ILOING
ADDp ESE LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY, ///I `//�� �y NEAREST
department. ) Iii �/ �V C.��T CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE OCESSED BY
CROSS ST. v CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL '�a _3
` COMPENSATION INSURANCE DESCRIPTION LOT NO. eLocK �wA
NO. OF BLDGS.
=%y7r/a 73i =LEi STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT / 19 NOW ON LOT / USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) E f
SIZE OF LOTS v EXISTING BLDG. �/ a
I certify that in the performance of the work for which this uso
permit is issued, I shall not employ any person in any manner o.. m, r�/'J� y
/-- /
so as to become subject to the Workers' Compensation Laws. MAIL 7 n/ # OCCUPANCY GROUP 3
ADDRESS I/ / 0.3 V
Date Applicant
rEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of crrY /7 NO.
Exemption, you should become subject to the A—... Iz
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USEGEOLGY INSPECTION ❑
deemed revoked. 1:1O ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi' SAFETY PERMIT ❑ (LIST ITEMS BELOW)
NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING
SPACES RE D PROVIp Ep D
License Number Lie. Class
y3 A ,u LIMITED TIME USE
Contractor Date yy3•S� OOT. AT.
I am exempt from the licensing requirements as I am a yy3'�A 'rir�3.3f/
licensed architect or a registered professional engineer SIZE of NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES J SIGNATURE
iness and Professions Code). FINAL APP R O V A L
PRESENT USE OF BUILDING
Lie.or Reg.No. Date �C-J �% 1 ,.• ��
' HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS / -L1
ON LOT AND USE • f .,f_ JL
I hereby affirm that I am exempt from the Contractor's HL.i ,Y
License Law for the following reason (Section 7031.5, Busi- .7 -7,lj I
ness and Professions Code): No. PARKING
SPACES PROVm ED 1, r
1, as owner of the property, will do the work and the i TEN
structure is not intended or offered for sale (Section
7044,Business and Professions Code)- TOTAL I AL 9uoO0
N( 4HECK
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING L
1 hereby affirm that there is a construction lending agencyn'
for the performance of the work for which this permit is li"�Ai`�7C ,LIi
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX, Dec. r�tII I1—�i�Illl ,_r)yI{J'y'F
Lender's Address
I certify that I have read this application and state that the PERMIT FEE V�'QrF i nil:i:IJ))
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
up��gppp the above-mentio e roR city for inspection purposes.
�c SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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