Loading...
HomeMy Public PortalAbout9812 LA ROSA DR_Miscellaneous__ 'WORKERS'COMPENSATION DECLARATION 76M444. - CE875(2-80) MISCELLANEOUS APPLICATION I hr' by affirm that I have a certificate of consent-to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Iq,;tIire, or a certificate of Workers'Compensation Insurance,or , a certified copy thereof(Sec. 3600, Lab.C.) Policy No. Company; •FOR APPLICANT TO FILL IN BUILDING /-7 ElADORE55 /d5 Certified copy is hereby furnished: \ BU ILomG /'❑ LOCALITY AODRE55' _ C Certified copy is filed with the county building inspection ' / NEAREST department. LOCALITY 9CROSS sT. Date Applicant NEARESTDISTRICT N GROUP TYPE / PROC SSEDBY - CRoss ST. i3 CONST` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V1 COMPENSATION,INSURANCE DESCRIPTION Lor No. BLocR `AAPNo. /� GR W,,. STATE MAJOR SECOND LOCAL >_ (This section need not be completed if the NOC�O/ 1�ICIRCLEI. OF SLOGS. a /l- Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS y by the permit is for one hundred dollars ($100) or less.) usE of SIZE OF LOT EXISTING BLDG. /1 1 certify that in the performance of the work for which'his' - - Q permit is issued, 1 shall not emplov any person in any manner gWNER '. �' � H .so al to become subject to the Workers' Compensation Laws. MAIL ��77 _ �T '' p ' OCCUPANCY GROUP I K-`-' W ADDREss 014- .1 w 0- Date- Date Applicant U) E. 71 Z NOTICE TO APPLICANT: If, after making this Certificate of crtr no. - �lf OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLItATION FOR EXIT HARDWARE: Wit It comply With Such provisions Or this permit Shalt be TRAILER USEGEOLOGY INSECTION - EJP ❑ No Spec. Knowl. Eldeemed revoked. LICENSED CONTRACTORS DECLARATION occurwrvcv INSPECTION Panic Devices• ❑ - I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT El (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 and PARXINe. effect. SPACES REO'D D PROVIDEO+ � License Number Lic.Class— LIMITED TIME USE . Contractor Date DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No. of G©°�-q xTu S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES - mass and Professions Code). FINAL APP R O Y A L PRESENT USE OF BUILDING Lic.or Reg.No. ,Date _ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that- 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and PrOfe5510u5 Code): SPACES PROVIDED 17j7. /.p A 1, as owner of the property. will do the work and the 1 s structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING 2 !° ` ! '6 2.5 0 ° CONSTRUCTION LENDING AGENCY . I hereby affirm that there is a construction lending agency - °'O'°'6 2 5 O cit for the performance of the work for which this permit is _ issued (Sec. 3097,Civ.C.). Q 2•6 —S'2- 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. 1 agree to comply with all County ISSUANCE FEE /O - ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize'representatives of this County to enter r ,up o the above-mentioned p P94Y for inspectiorvlf�pose ,SEE REVERSE FOR EXPLANATORY LANGUAGE Signal a of Permittee Da''tte``d