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Home My Public Portal About9166 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7E 44 (,, 84, MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a.certif"icate of Workers'Compensation Insurance,or a certVied'copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING OCALITV ADDRESS We LA effial CTM&- Certified copy is filed with e cou uildin ms ection LOCALITY NEAREST Dateddep rtme CROSS ST. rt Appllcan NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. CONST. CERTIFICATE OF EXEM9rION1FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY ' NO. (CIRCLE) STATE MAJOR SECOND LOCAL 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 SIZE OF LOT EXISTING BLDG. 9- I certify that in the,performance of the work for which this D permit is issued, I shall not employ any person in any manner OWNER Offi v so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 0 ADDRESS F- Date Applicant It Aw TEL a NOTICE TO APPLICANT: If, after making this Certificate of CITY OCCUPANT LOADCn Exemption, you should become subject to' the Workers' z 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. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 9 (commencing with Section 7000) of Division 3 of the Busi- ❑ LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING i I SPACES REp'D PROVIDED License Number Lic. Class PT LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requiremeiits as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). C PRESENT USE OF BUILDING FINAL APPROVALG Lic.or Reg.No. Date • HOME OWNER-BUILDER DECLARATION N Iry. OF EXIS B ILDINGSO FEE ON LOT AND I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section.7031.5, Busi- 0000-13MI 11/20/89 ness and Professions Code): NO. PARKING �pt q I, as owner of the property, will do the work and the SPACES PROVIDED &396 1 AM11:50 structure is not intended or offered for sale (Section V�L+ '7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING V I hereby affirm that there is a construction lending agencyI ie lO r; for the performance of the work for which this permit is I issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. �J Lender's Address V I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, bD and here author' representatives of this County to enter TOTAL. FEE o thea enti ned p p rty r inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee ate 1 I •� WORKERS'COMPENSATIONDECLARATION 76nn444.. .E 875(11-84) MISCELLANEOUS APPLICATION J� ' 4,� hereby affirm that I have a certificate of consent to self ,insure, or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified opy thereof(Sec. 3800,Lab.C.). Polic No. ompany =F71r � TFGY�If7 FOR APPLICANT TO FILL IN BUILDING ADDRESS !lfL¢ Certified copy is hereby furnished. BUILDING J 6 /l_S Q /)� LOCALITY XX''1ADDR•E53 ko Z Certified copy is filed with the county building inspection T LOCALITY 4 _ n p �7 p— NEAREST department. /y yy. ;y - v� 7 /b CROSS ST. Date Applicant ��u C' NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS�ST. D� CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK AAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF BLDGS. (This section need not be completed if the work invclved TRACT NOW. ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF / I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG. CD permit is issued, I shall not employ any person in any manne��v;` _L-— MI o P P �•�= OWNER.Q,f_-_.b Ll'1-'Zrd 1P1 �ILG G/ 1` J so as to become subject to the Workers' Compensation Laws. /y�/�/�/�n OCCUPANCY GROUP � MAIL �/� �O/A�//iC.'1 Vv �� W ADDRESS 4� {��-� Date Applicant _ q n NOTICE TO APPLICANT: If, after making this Certificate of CITY jH x NO. O/O ,� 3 — l OCCUPANT LOAD Exemption, you should become subject to the Walkers — Compensation provisions of the Labor Code, you must forth AP LIGATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. occurANcr INSPECTION ❑ Panic Devices LICENSED CONTRACTORS DECLARATION l 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- No. OF EXITS ness and Professions Code, and my license is in full fort,az r effect. -XI .Nc1IIle,,s'Of,�7:b Us-1Vm—e--q--s"') PARKING REQ'D I I PROVIDED --� — L SPACES IIJJ License Number Lic. Class (�ylf elul L' �r k LIMITED TIME USE Contractor Date DATE DATE PROM: TO: 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer slzE of NO. OF INSPECTOR'S SSPE ATUR•E acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL A ROVAL9 PRESENT USE OF BUILDING I I-I Lic.or Reg.No. Date 1 — - HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �/p ON LOT AND USE V - - �• (7i_ilti)—f)illjl. I hereby affirm that I am exempt from the Contractor's __ License Law for the following reason (Section 7031,5 Busi- 2947 { i-1�� ness and Professions Code): ;' NO. PARKING ❑ 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING 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. OCC. Lender's Address _ 1 certify that I have read this application and state that the PERMIT FEE 25 - 00 above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, 4 and hereby authorize presentatives of this County to enter TOTAL FEE 25 .00 upon the ab ve-mentio ed property for inspection purposes. I ` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date