HomeMy Public PortalAbout9022 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (2-80) MISCELLANEOUS APPLICATION
• CE 875 �J
I hereby affirm that I have a 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 a
ADDRESS
❑ Certified copy is hereby furnished BUILDING ! LOCALITY
Eldepartment
' �� " ,
Certified copy is filed with the county building inspection
,�+ �, / NEAREST
7idepartment OC ALITY / 11L CROSS ST
Date Applicant AREST DISTRICT NO. GROUP TYPE PROC SED 19Y
1 CROSS 3T. Y" e-,- - ��"/�a t� �� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J �
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAF sl /G Gl NIG.-Ar
NO (CIRCLE)
STATE MAJOR SECOND LOCAL >_OL-!!
NO. OF BLDGS a
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE FCJAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less.) USE OF ,- U
SIZE OF LOT EXISTING BLDG. Cs tr
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
so as to become subject to the Workers' Compensation Laws AIL Z OCCUPANCY GROUP Q U
W
ADDRESS Y032 I l.t.�..a�
Date Applicant ain
NOTICE TO APPLICANT If, after making this Certificate of i., CITY G' NDL 2 6- 7Y (p 2 OCCUPANT LOAD Z
Exemption, you should become subject to the Workers' AP KATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION
❑ C] No Spec. Knowl. El
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 PARKING
effect - - SPACES ` REQ'D O PROVIDED D
License Number Lic Class
LIMITED TIME USE
Contractor Date ' DATE DATE
FROM TO
❑ 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). -9-RESENT USE OF BUILDING .,r
Lic.or Reg.No. Date V
HOME OWNER-BUILDER DECLARATION NO.of EXISTING BUILDINGS
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 25 Jr
structure is not intended or offered for sale (Section
7044, Business and Professions Code). s
ROPOSED USE OF BUILDING CL a,Y YL 8'8
1
CONSTRUCTION LENDING AGENCY o
I hereby affirm that there Is a construction lending agency
-for the performance of the work for which this permit is 1�', 0 8,-8 2
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
ordinances and State laws relating to building construction, TOTAL FEE •d `
and hereby au once r entatives his unty to enter
upo bo a-men prop coon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigrallirre-of Permittee Date