HomeMy Public PortalAbout9808 LA ROSA DR_Miscellaneous__ R'ORKF.RS'COJIPENSpT10N DECLARATION CE 87MISCELLANEOUS APPLICATION
I hereby a {�
• - 76 44a
(11-84) LJ
affirm that 1 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.Q. '
Policy No. Company FOR APPLICANT TO FILL IN BUILDING �y /
wDORESS
Q Certified copy is hereby furnished. BUILDING kq
A. D� -�
ADDS ESS �O LOCALITY
Certified copy is filed with the county building inspection LOCAur / / � NEAREST
department. moss sr.
Date Applicant NEAREST n pISTfl ICT NO GROUP TYPE lj PR SED BY
CROSS ST. '� f CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1
COMPENSATION INSURANCE DEscRlPnory LOT NO. I BLOCK IaxwA
rva.A (cIR CLe) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT U E ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) I/ USE OF ?� o/'f�p�✓Cti'
SIZE OF LOT EXISTING§Ldd d
I certify that in the performance of the work for which this ED
Permit is issued, 1 shall not employ any person in any manner OWNER 7`�R
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPMAI
/I
ADDRESS
Date Applicant uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY /}O �. No�/ (7/ OCCUPANT'LOAD
Exemption, you should become subject to the Workers' gppLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions Or this permit shall be TRAILER USE E] GEOLOGY INSPECTION ❑ No Spec. Know[.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
1 hereby affirm that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust- SAFETY PERMIT (LIST ITEMS BELOW) NO. OF EXITS -
ness and Professions Code, and my license is in fall force andl �Mrn Q r�D�
effect. KXl PA R N INo
�t�,�1 '�1 / �-t� SPACES BE Wo D PROVIDED
License Number Lie. Class T.-1"'J yS2Q �� tlt>
LIMITED TIME USE
Contractor Date - Cb'`>�/0�1 �_ DATE DATE
I am exempt from the licensing requirements as 1 am aTI tl1h ' /.AA PJF -Dl-
licensed architect or a registered professional engineer slzE of 111,14D TI O GOV£R I NO. F INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. \' STORIES SIGNATURE
iness and Professions Code).
Lie.or Reg. No. Date PRESENT USE OF BUILDING / /D PNGD FINAL APPROVAL
HOME OWNER-BUILDER DECLARA'T'ION NO,OF EXISTING BUILDINGS
N
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor's �I,�1�
License Law for the following reason (Section 7031.5, Busi- (]S-IL y�1`-�4_%
f
tress and Professions Code): NO. PARKING . .ti0�?_ {
1, as owner of the property, will do
PROVIDED do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code). [I I I AL °'8-0 50
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING
uh,l•� ;
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 4/4,1
PROPOSED MAX. OCC. '
Lender's Address /' `u-n- ?, �
!/ '-� a °1•L.
1 certify that I have read this application and state that the PERMIT FEE Rht
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
on the ove tioned pr pert y or inspect' n pup-es.
( -• l� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermittee �7 Date