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Home My Public Portal About9926 LA ROSA DR_Miscellaneous__ R'ORK8R5'COMPENSATION DECLARATION a CE 875(1 t84) M ISCELLANEOUsAPPLICATION {1 CE 87LI I hereby a cert that,,l have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure.or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.Q. • _ Policy No. Company FOR APPLICANT TO FILL INBuiLD�NG 99Z ADDRESS 7 Q Certified copy is hereby furnished. BUILDING 0191 LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY ` rvEwR EST department. CROSS ST. Date Applicant NEAREST DISTRICT N�/O/�. GROUP TYPE ��// CESSE° BY CROSS ST. , aV r/_J CON STS// CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'N` D frj COMPENSATION INSURANCE DESCRIPTION Lor No. BLOCK HIGHWAY rvO.P I<Iw CIH) S TE MAIOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITI by the permit is for one hundred dollars (5100) or less.) USE of I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG. �p o permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL T OCCUPANCY GROUP 3 0 Date Applicant ADORE �cc �Sufi -fes!r'y.e. TEL. OCCUPANT LOAD �� y d NOTICE TO APPLICANT: If, after making this Certificate of CITY No. Z . rn Exemption, you should become subject the Workers' APPLICATION FOR EXIT HARDWARE: z Compensation provisions of the Labor Code,, you must forth-- ❑with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under pxovisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Bust- NO. OF EXITS ness and Professions Code, and my license is in full force andG9 effect. PARKING SPACES REO'D PROVIDE. License Number Lic. Class LIMITED TIME USE Contractor Date D.,E D.TH I am exempt from the licensing requirements as I am a Of 'T `s licensed architect or a registered professional engineer SIZE OF rvo. OF INSPECTOR'S EXISTING BLDG. STORIES SrATURMacting in my professional capacity (Section 7051, Bus- iness and Professions Code). FINAL APPROVAL o-2 PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ?Ij ON LOT AND USE I hereby affirm that I am exempt from the Contractor's Fi:(;Teg License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 1 ITErE: 7044,Business and Professions Code). Ti_ITy_ '?- >e -F._+ CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING _yFC:,,i. i I hereby affirm that there is a construction lending agency - for the performance of the work for which this permit is 1-1itif�'7t ,illi issued(Sec. 3097,Civ. C.). Lender's Name PROPOSED MAX. OCG J.U-00-000 Lender's Address sD D� 13. 2 PERMIT FEE I certify that I have read this application and state that the - 1 above information is correct. 1 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 C73 19 upon the above-mentioned property for inspectio)i purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure e o r ttee Date?