HomeMy Public PortalAbout9130 LAS TUNAS DR_Miscellaneous__ ERS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
I",ebym that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or.a certificate of Workers'-Corn pensation Insurance;or
a certified Copy thereof(Sec..3800,Lab.C.)
Policy No.—, Company FOR APPLICANT-TO FILL IN BUILDING.`'
DDRESS
30
Certifiedcopyis hereby furnished. UILDING LOCALITY, '
ADDRESS
0 ,Certified copy is filed with the county Building inspection NEAREST
department.. LOCALITY 4 CROSS*ST.
iclry
Date Applicant NEAREST. 'L
^ DIS ICT JV�O'/ _GRpUP TYPE PR E"D BY
CROSS;ST. L o - L(//J \I/ 6_ 4 CON -
T�
CERTIFICATE OF EXEMPTION FROM,WORK'ERS'.
LEGAL,,
ON LOT NO. BLOCK MAp ' HIGHWAY
COMPENSATION INSURANCE' s }
HO. (CIRCLE) TATEMAJOR SEC D LOCAL .a
(This-section need not be completed_if the work1nVOIVed TRACT NOW ON LOT NO. OF BLOGS. USE.ZONE 'SPECrAL CONDITIONS O
by the permit is for one hundred`dollars ($100) or less.) USE of
• -=
SIZE OF LOT EXISTING BLDG. -
I certify that in the performance.of thework for which this. �J O
permit is issued, I shall not employ any person in any manner _.OWNER
so as'to become subject to the Workers' Compensation Laws. wII OCCUPANCY GROUP �� W
.. - ADDRESS `,�.. r .-
Date Applicant.
.TEL. Z
NOTICE TO APPLICANT: If, after-making,this Certificate of. clryP&Ap" No. _ J> OCCUPANT LOAD".
Exemption, ,you should become subject to the 'Workers' APP LICA ION FOR EXIT HARDWARE:
Compensation provisions.of the Labor Code, you must forth-
with comply with such provisions-or this permit shall be - TRAILER USE. GEOLOGY INSPECTION a No Spec. Knowl! O
deemed:revoked. -
LICENSED.CONTRACTORS DECLARATION OCCUPANCYwsPEcnoNPanic DeVIC2S' EJ '
I hereby-affirm that I am licensed under provisions of Chaptei SAFETY PERMIT q (LIST ITEMS BELOmi)' No. of Exlrs
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and
usiness'and Professions Code, and my license is in'fulI force and
effect, - SPACES
SPACES INGREq'D O PROVIDED _�
License Number Lic.Class-77
LIMITED TIME USE
Contractor Date DATE, DATE
. - FROM: TO:
lam 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 S GNATURE
'Inessand Professions Code)., RESENT'.USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date ✓ ��
HOME OWNER-BUILDER DECLARATION No. of NTiNG:9uILDINGs
• ON LOT AND USE
I hereby affirm thaf-I,.am exempt from the Contractor's
License-Law for the following reason-(Section 7031..5,'Busi-
ness and Professions Code): 40—PARKING
PACES PROVIDED
0 I, as owner of the property, will do.the work and the
structure is not intended or offered for-sale (Section
7044, Business and Professrons.,Code). P OPOSF-D,USE OF,BUILDING � 4 5'5'7 A
01E&
AJ 9
CONSTRUCTION LENDING AGENCY .
I- hereby' affirm' that there is. a construction lending agency, # • •-o •
for the performance of the work for which this permit is' �\ •,• o • • • o En.
issued(Sec.3097,Civ.C.).
Lender's Name - PROPOSED MAX..OCC.
0.4,3'0 8,6
Lender's Address PERMIT FEE
I certify that •I have read this application,and state that the
above information is correct: Yagree to comply with 511-County. ISSUANCE FEE
ordinances and e.laws relating to building construction, Torwu FEE
a hereby authoriz .r pr
tatives of this CouVtyt entep e -bQve-men i ed operty for inspect' oses. SEE REVERSE FOR EXPLANATORY LANGUAGE .
sigv7oture orrermittee at