HomeMy Public PortalAbout9936 LA ROSA DR_Miscellaneous__ WORKERS'COM11PENSATION DECLARATION 7fiM444 L ' c
CE 675 (2-80) MISC LLANEOUS APPLICATION
'1 hereby affirm that I have eeomof consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
Compensation Compensation Insurance,or
a certified copy thereof(Sec.3600,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
A
DORE65
Certified copy is hereby furnished. BUILDING / _ LOCALITY
B n
❑ ADDRESS
Certified copy filed with the county building inspection NEAREST
LOCALITY�'�
department r. h c 1-4
Ross ST. I til
Date Applicant NEAREST OISICT NO. G VPFYIPE PROCESSED BY
CROSS 6T. I may. ` t U� CONST. •�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J
COMPENSATION INSURANCE 0ESCRIPTIory LOT NO. BLOCKMA I— HIGHWAY T
� (c,PCCE) STATE MAI SECOND OCAL 0-
NO. OF BLOGs.
(This $CCtlnn need not be completed if the Work involved TRACT NOW ON LOT n� USE3 ..NE SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT E%ISTING BLDG. 0
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 Vit i-
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP (� ,� W
ADDRESS 4� O v\ a
Date Applicant Z
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY ' No. —Cf 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 USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ N0 Spee.Devices
El
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION PBDIC DEViC@S
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
nessand Professions Code, and my license is in full force and /w. 1T , 6y,e} / dtls e PARKING.
effect. V VV SPACES REO'O PROVIDED
.�/
License Number Lic. Class O COM ll"nce ,A &/41
l✓t LIMITED TIME USE
Contractor Date (vai .tech/-. -Por (/k -,41- o„TE oArE
I am exempt from the licensing requirements as I am h V/r? dsf-- . 'd / r7
licensed architect or a registered professional engineer SIIE OF NO. OF INSPECYOR'S
acting in my professional capacity (Section 7051, Bus- Exlsn rve BLDG. Sr
srOR1Es sle TORE
iness and Professions Code). /+AI
PRESENT USE OF BUILDING 1 V�.eEA k-"Q sc_ FINAL APPROVAL
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor'sffid ` ' ll
License Law for the following reason (Section 7031.5, Busi-
nessand Professions Code): V
NO. PARKING y g y SPACES PROVIDED
1, as owner of the property, will do the work and the a o 0 0 3 O
structure is not intended Ilr offered for sale (Section
7044, Business and Professions Code). 1 ° - 8050
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency L'?
for the performance of the work for which this permit i5 03 1 3—8 4
issued(Sec. 3097,Civ.C.).
Lender's Name PROPOSED MAX. Dec.
Lender's Address PERMIT FEE d
I certify that I have read this application and state that the
abov infor ation is correct. I agree to comply with all County ISSUANCE FEE % •SS_,
ordil Dees nd State laws relating to building construction, TOTAL FEE •�
and •reb. authorize rel resentutives of this County to enter
upor he ov i 7 d= inspec ion p rpuses. SEE REVERSE FOR EXPLANATORY LANGUAGE.
'Sig Lure of Permittee ate