HomeMy Public PortalAbout9231 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 16M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
I hereL�yaffirm'that I have a certificate of consent to Self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION-
insure,
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 � S�.
ADDRESS.
❑ 'Certified copy is hereby furnished. BUILDING LOCALITY ..
ADDRESS.
❑ Ce-rtified copy is•filed with.th6 county building inspection NEAREST
department. - LOCALITY CROSS ST.
Date Applicant NEAREST , DISTRICT G TYPE PRO ED-BY
• - CROSS ST. ` - CON -T '
CERTIFICATE OF EXEMPTION FROM.WORKERS' - LEGAL VVV '`
COMPENSATION INSURANCE DESCRIPTION LOT NO.• BLOCK MAP RIGH AV
- NO. (CIRCLE) STATE MAJOR SE4D LOCAL-
Ld
NO. OF'BDGS. USE ZONE SPECIAL CONDITIONS _ Q
(This section tieed not be completed_if,-the work-involved' TRACT NOW ON LOT
by the permit is for one hundred dollars ($100) or less.) USE OF
- SIZE OF LOT EXISTING BLDG.
I certify, that in the performance of the work for which this 0
permit is issued; I shall not employ-any person in any manner OWNERi� I-
so as to become-subject to the Workers' ComOCCUPANCY GROUP_Compensation Laws. MAIL
W
ADDRESS S N
?),I ) i& ,
Date Applicant,
NOTICE TO,APPLICANT: If;,after snaking this-Certificate of CITY NO. a�s—29'� 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 USEE] GEOLOGY INSPECTION - - NO Spec.•Knowl. ❑, -
deemed revoked. Panic Devices ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION --
1 hereby affirm.that I am licensed under provisions of Chapter SAFETY PERMIT Q . (LIST-ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with--Section 7000) of Division 3 of the Busi=
ness and Professions Code, and my license is in full force andPARKING.
effect. "" I SPACES I D O PROVIDED
-- ' - - 11�� •
License Number Llc. Class LIMITED TIME USE
Contractor Date DATE DATE
❑
FROM: To:
I am exempt from the licensing requirements as I am
licensed architect or a registered professional engineer SIZE OF NO. OF
a INSPECTOR'S
acting in my'professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING -
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.of EXISTING BUILDINGS
a
•- ON LOT AND USE
'
-, - - , - . X455, 1 A
I hereby affirm that I am exempt 'from the Contractor's
,License Law for the following reason (Section 7031.5, Busi- # •� 3
.Hess and Professions Code): NO. PARKING
_ SPACES PROVIDED
❑ I, as owner of-the-property,-will do the work and the 8 0.5 0
structure Is not intended or.offered for sale (Section
x
7044, Business and Professions Code). PROPOSED USE OF BUILDING 8 Q 5 0 v
CONSTRUCTION LENDING AGENCY 04"29..-8 6 '
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. `
Lende'r's Address PERMIT FEE
I certify that I:have read this application and state that the `+
above information is correct.I agree to comply with,all County ISSUANCE FEE (�
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of•this.County to enter
ugn2i the above-mentioned h roperty for inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of mittee Date