HomeMy Public PortalAbout9088 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875
(11-84) M p SC E L LA N EO U S APPLICATION
11, 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 FI LL IN BUILDING lO�d C
ADDRESS !1
Certified copy is hereby furnished. XX BUILDING
ADDRESS � � L LOCALITY
�T
0 Certified copy is filed with the county building inspectionXX LOCALITY
NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO GROUP TYPE CESSED BY
CROSS ST. `O i _ CONST ;,�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J ( ��
COMPENSATION INSURANCE , DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO (CIRCLE)
NOOF BLDGS.
(This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE of Lor EXISTING BLDG. CD
permit is issued, I shall not employ any person in any manner OWNER Of property: J
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP •�dZ o
ADDRESS'- �S ��/ t--
Date Applicant LUPI
NOTICE TO APPLICANT If, after making this Certificate o CITY �� TEL
��v✓�� 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 ❑ GEOLO'GY INSPECTION ❑ No Spec. Knowl. ❑
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)
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 X Nc'IIIle Of BUS7rieSS• GO C
effect PARKING REq D D PROVIDED
SPACES JJ
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM TO
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).
X FINAL APPROVAL �j_l�-4
PRESENT USE OF BUILDING
Lic.or Reg.No. Date Oj�
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING ILDINGS OA $
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ll/J c
License Law for the following reason (Section 7031.5, Busi- l
ness and Professions Code) NO PARKING
1, 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 X 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 25.0
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 25.00
upon the above- entioned pr p ray inspecti purpos
EE REVERSE FOR EXPLANATORY LANGUAGE-
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SignatwOof P m tee te/ 7