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HomeMy Public PortalAbout9132 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION— . 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 ADDRESS ❑ Certified copy is hereby furnished. BUILDING j H Y A r // LocAurY ADDRESS . 1. A S I VA) AJ T �L 1. Certified copy is filed with the county building inspecti$n /// NEAR BST department. LOCALITY AE7 ,l ' e � CROSS ST. Date Applicant NEAREST �(� IG DISTRICT NO. GROUP PE �/�RESSED BY CROSS ST. 3ti/ (,,, r a CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �- COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK RIGHWAY NO. : - (CIRCLE) STATE MAJOR SECOND LOCAL d 'NO. OFLOT USE ZONE SPECIAL CONDITIONS O (This section need not be completed,if the work involved TRACT Now dr, Cor 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 the work for,which this 0 permit is issued, I shall not employ any person in any manner -OWNER �p A v -�• so as to become subject to the Workers' Compensation Laws. MAIL �f /� �+ ) e ! OCCUPANCY GROUP Ace �.' . A:DDR ESS (� t As V A-� A S , Date Applicantn © NOTICE TO APPLICANT` If, after making this Certificate of c�xv'^�/y fI/. Ci T rTioL' � ''7 g �y 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 USEGEOLOGY INSPECTION No Spec. Know[. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I.am licensed under provisions of ChapterSAFETY PERMIT I (LIST ITEMS eELow) 9 (commencing with Section 7000) of Division 3 of the Busi- NO.'OF EXITS iness and Professions Code, and my license is in full force-and PARKING. .effect, SPACES REO'D I I PROVIDED o �� 11 License Number Lie.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 7651, Bus- EXISTING BLDG. STORIESSIGNATURE iness.and Professions Code). PgE SENT.USE OF BUILDING _`j •G FINAL APPROVAL /�r Lie.or Reg.No. Date � r U T1 HOMEOWNER-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'703,1.5, Busi- ness and PIOfeSS10n5.00de): NO. PROVIDED 2i3 4 3.9 A ❑. 1,'as owner of the property,.will do the work and the .. structure is not intended or offered for sale (Section 7044, Business and Professions Code). .# o I o'o. o'�.8 L ,- ,. • ,: 'O"POSED USE OF BUILDING !..-; r ,0,0.'0+0 O' O O:Zi CONSTRUCTION LENDING AGENCY `. I h i .� I hereby affirm that there .is a construction lending agency „� 4—8 4 for the performance of the 'work for which this permit is , a 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 and hereby authorize re entatives of this County to enter up he•above-m do ed property or inspection purposes. SEE REVERSE-FOR EXPLANATORY LANGUAGE ' Signature of rmittee Date