HomeMy Public PortalAbout9077 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M44,4 4
a-) , CE 875 (2180) MUS'l ELLANEOUS APPLBCA'TIO� 1
I hZreby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure, ur a clrtiticate of Workers'Compensation Insurance,or
a cer;;ied copy thereof(Sec. 3800,Lab C.)
Policy No. Company FOR APPLICANT TO FI L IN BUILDING
ADDRESS
❑ Certified copy Is hereby furnished BUILDING LOCALITY
R E S S
Elcopy Is filed with the county building mspectio NEAREST
department LOCALITY CROSS ST.
Date Applicant NEAREST DISTRICT NO GROUP TYPE• �ESSEDCROSS ST e �� UP TYPE'CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALCOMPENSATION INSURANCE DESCRIPTION LOT NO. , j BLOCK mAP HIGHWAY STATE MAJO }
NO (CIRCLE) a•
(This section need not be completed if the work involved TRACT S U� NO ONB ors USE ZONE S ECTAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or,less.) U
USE OF TI
SIZE OF LOT EXISTING BLDG
I certify that-m the performance of the work for which this Q
permit is Issued, I shall not employ any person in any-manner ' OWNER Z (—
so as to become subject to the Workers' Compensation Laws M UPANCY GROUP }�^ L W
DRESS D I�
Date Applicant rEL Z
NOTICE TO APPLICANT If„after making this Certificate of CITY e No. 42 i OCCUPANT LOAD
Exemption, you should become subject to the Workers' APP CATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth- ,
with comply with such provisions or this permit shall be TRAILER USE E] GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked Panic Devices El CONTRACTORS DECLARATION - OCCUPANCY INSPECTION
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 I 1 Cafl t I s Name — Y PARKING.
effect SPACES REQ�D E= PROVIDED
License Number Lic.Class Home Address - (� �
LIMITED TIME USE
Contractor Date DATE DATE
FROM TO
I am exempt from the licensing requirements as I am b PKone —
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
i
mess and Professions Code) 'SENT USE OF BUILDING S FINAL•APPROVAL2
Lic.or.Reg.No. Date
' r
NO OF EXISTING BUILDINGS 1 '
HOME OWNER-BUILDER DECLARATION 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
r
SPACES PROVIDED ;� �.: t?
1, as owner of the property, will do the work and the
structure is not Intended or offered for sale (Section # a o o o
7044, Business and Professions Code)
POSED USE OF BUILDINGA f ,)
V O
CONSTRUCTION LENDING AGENCY (
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 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 ISSUANC FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes SEE REVERSt FOR PLANATORY LANGUAGE
Signature of Permittee Date