HomeMy Public PortalAbout10217 LA ROSA DR_Miscellaneous__ WORK$RS'COMPENSATIONDECLARATION CE 875 MISCELLANEOUS APPLICATION
Y CE 875 (11-84)
I hereby affirm certificate
lia"Worke s' !bmpe of consent to sell COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of'1Vorkers'L•�o�m,pensation Insurance,or
a certified co 1e eof 3 00,L C. .
Policy N� 2y ' Lny e —,p"— ,_&0 FOR APPLICANT TO FILL IN BUILDING /
n �1 ADDRESS
Certified copy is hereby furnished. BUILOI NG /Da/ Ln Q.S�-I
tti�p. 7 Xd,405�
ADOR E55 LOCALITY I I
y�ry Certified copy is filed with t 'county bugWing inspecti
lJ��� LOCALITY /�J/� /) NEAREST 41,
departure�p�t � _ /GC—i („r1� CROSS ST.
Date?/d',1� Applican NEAREST DISTRIC� GRAU! TYPE / PRO E ED BY
CROSS ST. Q�'�V CONfjJ.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL YY
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 1...AY STATE MAJOR S CONO LOCAL
rvo (c,w CL6)
NO. OF BLOCS.
(This section'need not be completed if the work ved TRACT Now ON LOT USFSPECIAL CONDITIONS
by the permit is for one hundred dollars (SI or less.) n� USE of
SIZE OF LOT / X G. EXISTING BLDG. - d
I certify that in the performance of the for which this Ca
permit is issued, I shall not employ a erson in any manner ow,ER S - `�'
so as to become subject to the I ers' Compensation Laws. MAIL �� G OCCUPANCY GROUP .x o
AODREss � B f�6T�' `
Date A cant
TEL .�/S OCCUPANT LOAD
NOTICE TO AP CANT: If, after making this Certificate of CITY - NO. rte.,
Exemption/you should become subject to the Workers' m
Compe ton provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
wi .in
with such provisions or this permit shall be - ❑ ❑ No Spec. KnoWl.
"d_
eemed rev
d.w TRAILER USE GEOLOGY INSPECTION
LICENSED CONTRACTORS DECLARATION occuw wacr INSPECTION - Panic Devices
I 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 71
ness and Professions Code,and my license is in full force and p '
effect. G PARKING
fl E0'O D PROVIOEO D
`' SPACES
License N1 mbe ic. Class ��pVVYY••JJ", I✓A-� T/8' —
9 LIMITED TIME USE'
Contra DATE DATE
I am exempt from the licensing requirements m.l am a
licensed architect or a registered professional engineer SIZE of oo INSPE crD R's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. -To- .sle ATURE
iness and Professions Code). - - FINAL APPROVAL
PRESENT USE OF BUILDING ✓ /^
Lic.or Reg. No. Date L/
HOME OWNER-BUILDER DECLARAT , No. of Exlsnrvc BUILDINGS
ON LOT AND USE
I hereby affirm that 1 am exempt fro the Contractor's
License Law for the following reaso ection 7031.5, Busi-
ness and Professions Code): NO. PARKING
El1, as owner of the pr rty, will do the work and the SPACES PROVIDED -
structure is not i ded or offered for sale (Section •�$2`7'A,
7044,Business Professions Code). -
C TRUCTION LENDING AGENCY PROPOSED USE OF BUILDING /. '#J� 3 Q
1 hereby irm that there is a constmetion lending agency , - -(j• E•Fj Q 5.0'
for t1�e performance of the work for which this permit is.
`
iss,suEd(Sec. 3097,Civ.C.). - ,. . g,a.5p5
Lender's Name
PROPOSED MAX. OCC.
Lender's Address - - 2 $7
PERMIT FEES O �'O I
I certify that�1 have read this application and state that the -
above information is correct. 1 agree to comply with all County ISSUANCE Fee 'S0
ordinances and State laws relating to budding construction,
and hereby authorize represents Ives of this County to enter TOTAL FEE S -
upon tt above-mentioned pro t or inspection purposes. -
�_✓h' � �, a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per ttee Date