HomeMy Public PortalAbout9450 LA ROSA DR_Miscellaneous__ •-^� Wltfc'KERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
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 FI LL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING ,p SI - LOCAL.
-
ADDRESS
-0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST I /� DI XRICT NO. OUP TYPE PRO ESSED BY
CROSS ST. I/J (/� {� ` CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL _]
COMPENSATION INSURANCE DESCRIPTION Lo C 3 L. MAP HIGHWAY HW AV
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 /
I certify that in the,performance of the work for which this SIZE OF LOT 02 EXISTING BLDG. O
permit is issued, I shall not employ any person in any manner OWNERS ='
so as to become subject to the Workers' Compensation Laws. MAIL / OCCUPANCY GROUP -3 0
ADDRESS /L,L - U
Date Applicant T L. / '/� ur
NOTICE TO APPLICANT: If, after making this Certificate of CITY - NO. C!f���7Y-OS C/ OCCUPANT LOAD
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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
❑ E] No Spec. Know!.
deemed revoked.
OCCUPANCY INSPECTION Panic Devices ❑
LICENSED CONTRACTORS DECLARATION �
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- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. �(/KJ PARKINGREQ'D PROVIDED
SPACES
License Number Lic. Class '
LIMITED TIME USE
Contractor Date - - - - DATE DATE
FROM: TO:
El I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNO. OF /I INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �., 3 STORIES / SIG ATURE
iness and Professions Code).
PRESENT USE OF BUILDING �
FINAL APP-RPV-ALLic.or Reg.No. Date ]
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _.
ON LOT AND USE -
I hereby affirm that I am exempt from the Contractor's -• AXTA
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING - 3307 [- - 80.5
❑ I, as owner of the property, will do the work and the SPACES PROVIDED Z I ITS
structure is not intended or offered for sale (Section
`.:. TOTS �O:5fO
7044,Business and Professions Code). ,��} - .. �.�
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING �?S • }•:
I hereby affirm that there is a construction lending agency
001IM
for the performance of the work for which this permit is c
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. e"?".
?"
Lender's Address 36Uw36U I 1' Q
M Q �
� - - A111 �
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, y
and hereby authorize representatives of this County to enter TOTAL FEE C/
upon the abgve-men 'oned rof r inspection purposes.
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
!nature pe of Permittee Date