HomeMy Public PortalAbout9046 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N
I hereby affirm that I have a certificate of consent to self CE 875 (11-84)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 D `
ADDRESS (p
Certified copy is hereby furnished. BUILDING 0q } @ Q'tt
AD OR ESS �I t 1 OCA LITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT N �?CUp TYPE P ESSED BY
CROSS ST. Or��]!vin CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF HLD G3.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. d
I certify that in the performance of the work for which this
0-
permit is issued I shall not employ an C:)
p p y y person in any manner OWNER y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP2�:] o
Date Applicant ADORE S' y,El Air— ,I�,
NOTICE TO APPLICANT If, after making this Certificate of CITY NO. Gj= 9ps' OCCUPANT LOAD N
Exemption, you should become subject.to the Workers' tE z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE _
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemedrevoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect." `� IeVPARKING REQ'D PROVIDED
SPACES
License
License Number Lie. Class 0 IiG l�(IL�
" LIMITED TIME USE
Contractor Date DATE DA TG
,F� I am exempt from the licensing requirements as I am a
FROM: TO
licensed architect or a registered professional engineer SIZE OF NO. OF *INSC*TOR'Sacting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES mess and Professions Code). FINAL APPROVALPRESENT USE OF BUILDING Lie.or Reg.No. Date -
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE 4 � Ii�}
I hereby affirm that I am exempt from the Contractor's JO
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
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING,
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I 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 �Q-O
upon the above entioned property for inspection purposes.
/ ✓� SEE REVERSE FOR EXPLANATORY LANGUAGE
Y erNSignature oerm e Date