HomeMy Public PortalAbout8814 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have 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.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING �.
❑ LOCALITY
ADDRESS Certified copy is filed with the county building inspectionLss San Ce - '
NEAREST
department. LOCALITY - moss ST. --]_.
San
Date ApDiicant CA
NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY >_CROSS ST. S 1V .. — CONST. ' M
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL f C
COMPENSATION INSURANCE DESCRIPTroN LOT NO. BLOCK MAP U
OF
STATE MAJOR SECOND LOCAL
. LOSS. ND. (c,wCLEI y
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
NOJ
�- by the permit is for one hundred dollars ($100) or less.) USE of tL
SIZE OF LOT EXISTING BLDG.
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 Q
so as to become subject to the Workers' Compensation. Laws. MAILDDRESS - Reekenbaelt OCCUPANCY GROUP L
A
Date Applicant a
EL.
NOTICE TO APPLICANT: If,became
after making this Certificate of CITY No' OCCUPANT LOAD W
Exemption, you should became subject to the Workers' _4*4
Compensation provisions of the Labor Code, you must forth- A P I TION FOR EXIT HARDWARE: ♦—
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION
deemed revoked. C] ❑ No Spec. Knowl. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencipi with Section 7000)of Division 3 of the Busi-
ness and Pressions Code, and my license is in full force,and PARKING.
effect. SPACES REG'O PROvIDED
License Number Lic. Class - LIMITED TIME USE
Contractor Date DATe DATE
,....❑ OPo N: rD:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES � SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOMEOWNER-BUILDER DECLARATION NO. LLLSI SprintIng presses
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
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section i. I q Z A
7044, Business and Professions Code).
PROPOSED USE OF BUILDING if.• 0 G S S: C
CONSTRUCTION LENDING AGENCY C
I hereby affirm that there is a construction,lending agency P E � �7
for the performance of the work for which this permit isC„x O r ,7
issued(Sec.3097,Civ.C.).
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.I agree to comply with all County ISSUANCE FEE I`
ordinances and State laws relating to building construction, TOTAL FEE ,Q
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date