HomeMy Public PortalAbout9828 LA ROSA DR_Miscellaneous__ WORKERS'CONJPENSATION DECLARATION 76M444 -
CE675(2-80) MISCELLANEOUS APPLICATION "
1 herehyaffirm that I have a certificate ofconsentto selfCOUNTY OF LOS ANGELES ' BUILDING AND SAFETY DIVISION
Insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.) t
Policy No.—.Company FOR APPLICANT TO,FILL IN UADD
'BUILDING
RESS
❑ Certified copy is hereby furnished.' B
ILDINGC LRIES ,
AO DRE55. y ,.
Certified copy i4 filed with the county building inspection NEAREST
department - LOCALITY .rte crxossST.
Dale ApphCanL `NEAREST DISTRICT G OUP TYPE $ED BY
' .CROSS 5 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS" LEGAL "
COMPENSATION INSURANCE nest Rrvn oN LOT o. eLocK » ,cit LE }
NOP !/ I STATE MA/OR SECOND LOCAL a
N .OOF SLOGS:
(]'h15 SCCtIOn need not be -completed�if the woik�involved TRACT - NOw ON LOT USE Z NE SPECIAL CONDITIONS. O
. by the permit is for one hundred dollars (5100) or less.) _ V
USE OF
IZE OF LOT d 'EXISTING BLDG. - I cc
I certify that in the performance of*the'work'for which this - Q
permit is issued; I shall'not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws.• MAIL OCCUPANCY GROUP
AOORESsgIfT ='' a-
Datz Applicant - cn
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of tr @I T NO. 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 or ;this permit Shall be TRAILER USEE] GEOLOGY INSPECTION
OCCUPANCY INSPECTION El No Spec. Knowl. ❑
deemed revoked. - .. Panic ec. CBS ❑
'
LICENSED CONTRACTORS DECLARATION ❑
I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS a,
9 (commencing with Section 7000) of Division 3 of the Busi- _
ness and Professions Code, and my license is in full force and
PARKING
effect.
SFA
CES ' REO:. D FRONDED
License Number Lie.Class— -
LIMITED TIME USE
Contractor Date D.re OArc
FROM
❑ I am exempt from the licensing requirements as I am a TO.
licensed architect or a registered professional engineer SrZE OF INC. OF {/.,J��j /''� � I ? TOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES pp ��y f V `-•�""" ^TURF
iness and Professions Code). FINAL A PRZOVAL
PRESENT USE OF BUILDING
Lic.or Reg. No. Date—, _ ^ w
HOME OWNER-BUILDER DECLARATION NO. OF"EXISTING BwLDINGs - -
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's,
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): NO. PARKING
SPACES PROVIDED ,
❑ I, as owner of the property, will do the work and the - r
structure is not intended or offered for sale (Section 2''9 7 62 A
7044, Business and Professions Code). - PROPOSED USE OF SUILDtryG '
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency V- -1&0.1;50
for the performance of the work for w3lich this permit is•
issued (Sec. 3097,Civ.C.). I '^ • 8'0.5 0
Lender's Name
PROPOSED.MAX. OCC.
Lender's Address
,PERMIT FEE O•.� -
I certify that I have read this application and state that the - '•
above information is correct. I agree to comply with all County ISSUANCE PEE c._
ordinances and State laws relating to building construction, TOTAL FEE
and beret- [horize rept entatives of this County to enter
u e above-mentio d operty for inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature ofittee Date - - -
�, Vii.,