HomeMy Public PortalAbout10440 LA ROSA DR_Miscellaneous__ WOR.KERS'CMMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
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CE $7$ (11-841 LI
I hereby afirm that I have a certificate o£ 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
F-1ADDRESS
Certified copy is hereby furnished. BUILDIN
ADORE 5 G /L�4o �S� LOCALITY C \
5
Cextified copy is filed with the county building inspection LOCALITY NEAST
department. cRoRssEsr.
Date Applicant NEAREST
19R DIST 1 DISTfj�CT NQ, G„R�./p VP TYPE PROCESS V
CROSS ST. `\ ../I /Iy / IJ CONST../
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v U
COMPENSATION INSURANCE' OESCRIPT ION LOT NO. BLOCK HIGHWAY STATE MAJOR SECOND OCAL
NO. of BLDGS.
(This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) use of �I
I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG. o
permit is issued, I shall not employ any person in any mannet OWNER
so as to become subject to the Workers' Compensation Laws. �)AIL OCCUPANCY GROUP," ��-%•
MESS
ADDRESS
'G!-D �/� QQ�
Date Applicant w
NOTICE TO APPLICANT: If, after making this Certificate of CIrY —/y�L� rvo� OCCUPANT LOAD,
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with-such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
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 Busi- Liq NO. OF EXITS
ness and Professions Code, and my license is in full force and ' ,/
effect. V O `�/ // / PARKING
SPACES REq'D E� PROVIDEp
License 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 engineer srzE OF NO. of f INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- Ex[STING BLDG. STORIES J sl NATURE
iness and Professions Code). _/
71J(01t4 t- FINAL APPROVAL Z
Lie.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE '
I hereby affirm that 1 am exempt from the Contractor's
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 s\ ` I •\
structure is not intended or offered for sale (Section '. -J " I _ _ \ \ " �`6 49.-6•n
7044,Business and Professions Code).
h #,. : . : 30
CONSTRUCTION LENDING AGENCY PRoroscD USE of BUILDING `_ • 1 _ \
I hereby affirm tinct there is a construction lending agency �` •\ -•�I �-8 Q Jr
for the performance of the work for which this permit is J •.•w 8',Q 5 Q
issued (Sec. 3097,Civ.C.).
Lender's Name 0 2:1 1 _8 7
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct. 1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize 1"PreserItgtives of this ounty to enter TOTAL FEE IS
up a above-ment' t d pr erty for in ion purposes.
ISL2_—IP-47 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat e f Permittee Date