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Home My Public Portal About10320 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSAT[ONDECLARATION 76M444- i - MJSCELLANEOUS APPLICATION 'T' CE 875 12-80) :: O I heresy affirm icat I have a certifies Compensation Insurance, to self COUNTY.OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or - I a'certified copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING . ADDRESS ❑ Certified copy is hereby furnished. LOCALITY ub ING — ❑ AO DRE55 f t Certified copy is filed with the county building inspection /� NEAREST [r department. LOCALITY 01 cRoss sr. 77,1 Date Applicant EAREST , l l� pISTRICT N GROUP TYPE PR ESSED BY CROSSST. L!.L �'� CONST, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT rvo. BLOCK Mop Iaeww n0. [L• (Citic LE) STATE MAJOR SECOND LOCAL (L NO. Q ('1'1115 section need not be completed IP the wo[k involved TRACT NOW OF SLUGS.ON LOT USE ZONE S ECTAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. :��••. o I certify that in the performance of the work for which this n permit is issued, I shall not employ any person in any manner II. wrvER �Ky y i/ ,/ .� �I U so as to become subject to the Workers' Compensation Laws. X AIL a OCCUPANCY GROUP 111. , Q. L�33 ! AO DRESS Date Applicant N NOTICE TO APPLICANT: If, after making this Certificate of CI r NOL SS OCCUPANT LOAD Z Exemption, you should become subject to the Workers" ' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with Such provisions Or this permit Shall be TRAILER VSEGEOLOGY INSPECTION deemed revoked. ❑ C1 - No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ ) hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS a (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and - Pw RKirvG• effect. SPACES REO'. D PROVIDED D ,14icense Number Lie.Class LIMITED TIME USE Contractor Date DATE - DATE ❑ 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engiCeer SIZE OF rvo. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. - sro RIES sIG.A TURF iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING /✓ CJ•� Lic.or Reg.No. Date � 749.9A HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS o p ON LOT AND USE O e O e u'U I hereby affirm that I am exempt from the Contractor'se License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I L,09-8 3 I, as owner of the property, will do the work and the SPACES PROVIDED 1 ' structure is riot intended or offered for sale (Section 7044, Business and Professions Code). - - OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097.Civ.C.). �✓/Lender's Name PROPOSED MAX. Dec. .{ ' Lender's Address PERMIT FEE 1 certify that I have read this application and state that the above information i Orrect. I agree to comply with all County ISSUANCE FEE 1 ordinances and me laws relatin to fl ullding construction, TOTAL FEE and hereb thorize resentat' es of this County to enter . upon t o'e-m ro ty for insPee+on p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ermittee (1 D to V ' WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (2-80) rMISCELLANEOUS APPLICATION I hereby affirm 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.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS 7 ❑ Certified copy is hereby furnished. BUILDING 9�z�-/ j�Frj TN.MG.S �f'• 'L�r., (Lv OCALITY �� ❑ ADDRESS Certified copy is filed with the county,building inspection NEAREST department. LOCALITY LQ', cRoss sT. ' —� Date Applicant EAREST /� DISTRICT N G UP TYPE PROCESSED BY CROSS ST. 4 LrS rl V 1)20 � pl ' 'f CONST. ,CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK mwP IGwwP NO. � 1c,w Cce) STATE MAJOR SECOND LOCAL a NO. OF BLDGS. ' USE.ZONE SPECIAL CONDITIONS O (This section need not be completed if the work involved TRACT NO w ON LOT U by the permit is for one hundred dollars (5100) or less.) usE OF SIZE OF LOT E%)STING DG. rr Q I certify that in the performance of the work for which this O Permit is issued, I shall not employ any person in anv manner wNER AL CJ so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP ' AO LU DRESS ,` 13O �' r ^� a' Date Applicant < N NOTICE TO APPLICANT: If, after making this Certificate of e)rr�'�O xo 7� 3— j`�- LJ OCCUPANT LOAD z Exemption, you should become subject to the WorkersAPPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Cade, you must forth- with comply with such provisions or this permit shalt be TR gILER GEOLOGY INSPECTION No Spec. Knowl. deemed revoked. n ❑ E] LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION VPanic Devices ❑ r 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ )LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Bust- ' ness and Professions Code, and my license is in full force and PARKING. C,ffCCt. D SPACES REO'O PROVIDE Licerise Number " Lic. Class LIMITED TIME USE Contractor Date GATE onTE FROMi T.! ❑ I am exempt from the licensing requirements as I am a 'licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. SrO RIES SIGNATURE iness and Professions Code). ESENT USE OF BUILDING FINAL APPROVAL I Z-Z7'8 Lic.or Reg.No. Date RCRAJ 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, Busi- ness and Professions Code): SPESPVCROIDED : 2749.8A ❑ 1, as owner of the property, will do the work and the # a fie s 8,8 structure is not intended or offered for sale (Section 7044, Business and Professions Code). OPOSEO USE OF BUILDING CONSTRUCTION LENDING AGENCY ! I hereby affirm that there is a construction lending agency I#I LO(e/N G 49Lr£/2AT,o.tl s 11209-83 for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name ' PROPOSED MAX. OCC. " Lender's Address PERMIT FEE ` 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, TOTAL FEE and her authorize represents ti es of this County to enter - upoonn to ove-mentioned rop y for inspection yurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S n' ure ofer ittee e/Da/