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Home My Public Portal About9503 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 : , ,-_ 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.). - - fl BUILDING Policy No. Company FOR APPLICANT TO FILL IN 9so3 / /► P�j��/q ADDRESS Certified copy is hereby furnished. BUILDING j' LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY !-� NEAREST , department. ` C/ CROSS ST. Date Applicant NEAREST %0 ,J DISTRICT NO. GROUP TYPE PROCESSED BY 1 CRO_SS ST. G /e z/ CONST. - CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP - .1O.WAV • NO. (CIRCL'El 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 O.O/ EXISTING BLDG. / I certify that in the performance•'of.the work for which this permit is issued, I shall not employ any person in any manner OWNER 5-Y y so as to become subject to the Workers' Compensation Laws. MAIL OCCU ANCY GROUP o Date Applicant wDDREss w TEL. -"'NOTICE-TO APPLICANT'°If,aftei making`tliis`Ceitifrcate"of T--CITY /l � �No--�-- = a-�- _aCCUP_ANT LOAD_ Exemption, you should become subject to the Workers' Z APPLIC Compensation provisions of the Labor Code, you must forth- TION FOR EXIT HARDWARE. with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION a deemed revoked. ❑ ❑ No Spec. Knowl. 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 NO. of EXITS ness and Professions Code,'and my license is in full force and f effect. a PA R KIN G - SPACES REQ'D PROVIDED License Number Lie. ClassIr t - O L LIMITED TIME USE Contractor Date DATE DATE O El I am exempt from the licensing requirements as I am a O - FROM: TO: licensed architect or a registered-professional engineer SIZE OF p ' NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL G!� PRESENT USE OF BUILDING Lie.or Reg.No. Date ;;I HOME OWNER-BUILDER DECLARATION- NO. OF EXISTING BUILDINGS A1.1•i o3e ON LOT AND USE I hereby affirm' that I am exempt from the Contractor's f _- 2�°'��'+-` License Law for the following reason (Section 7031.5, Busi- - UTE ` ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED IFIL m structure is not intended or offered for sale (Section 45 7044,Business and Professions Code). CHECK 234 e't5 CONSTRUCTION LENDING AGENCY PROPosED SE OF BUILDING CHANGE .00 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. 0123 •u r111 j9 ' 1 'o!R0 Lender's Address "' •- Q� - - - --•-• 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 �(�, 340 ordinances and State laws relating to building construction, ,and hereby authorize representatives of this County to enter TOTAL, FEE upon he above-me p1tried property for inspectionur oses. f 1 — �,c(1 GIA-11? //,, ' � SEREVERSE FOR EXPLANATORY LANGUAGE !v/V SL�ignature of Pe ttee 7`-�' ate WORKF,RS'COMPENSATION DECLARATION 76M444 CE 875(11-84) MISCELLANEOUS APPLICATION I herP�l� affirm that I have a certificate of'consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensauon Insurance,or. I , ,, z 'fl a certified copy thereof(Sec. 3800,Lab.C.). .F, 1� . I •' Policy No. CompanyFOR APPLICANT,TO FILL IN BuS. S� 1 _ - ADDO RESS C 0 Certified copy is hereby furnished. BUIDDRLDE95 ING j ��S )SKI LOCALITY AT - _ Certified copy is filed with the county building inspection LOCALITYNEAREST department. P[,` Ci L.� CROSS ST. Date Applicant NEAREST //-�� ) DISTRICT NO. GROUP TYPE ESSED BY CROSS ST. �jI-ovfee L- O CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o _Y// COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS. NO. (CIRCLH) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE OF SIZE OF LOT Sx Z EXISTING BLDG. - I certify that in the performance of the work for which this CD p permit is issued, I shall not employ any person in any manner OWNER N�E(_O fi 0� Q PP ,SO RCFS s� so as to become subject to the Workers' Compensation Laws. aoDREss 'Q L ,p ` �� OCCUPANCY GROUP 3 0 Date Applicant R ,�', NOTICE TO APPLICANT:-If;after`making-this Certificate-of CITY L� C T NOI OCCUPANT LOAD N Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICA ION FOR EXIT HARDWARE: - — -- - with comply with such provisions Or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT p (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 �c effect. PARKING REQ'DO PROVIDED �. SPACES License Number Lie. Class C to � l�lo -- � LIMITED TIME-r. a Contractor Date • � DATE DATE Y FROM: TO: 77f17 �L{ I am exempt from the licensing requirements as I am a �� .�� —�—� _ . Fl-licensed architect or a registered professional engineer SIZE 16F NO. OFi RLQCTO RAS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES J IMMATURE iness and Professions Code). FINAL APPROVAL Z TI_1 m _e C PRESENT US OF BUILDING Lie.or Reg.No. Date - -- -- - �r 7:I� L 0 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS CHANGE .00 ON LOT AND USE (/ I hereby affirm that I am exempt from the Contractor's License Law for the following-reason (Section 7031.5, BusiG f—•� !111�1 _I� 1�1 1/26 /93 f� � ness and Professions Code): NO. PARKING �//� /p' L y(�' �-/ I, as owner of the property, will do the work and the SPACES PROVIDED O/f/ f�7�! i AM 8:57 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 z 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 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, v and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned pro y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ture cf Permittee Date