HomeMy Public PortalAbout9133 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 'r µ
ADDRESS
❑ Certified copy is hereby furnished. (-"BUILDING
LOCALITY
ADDRESS
Certified copy is filed with the county building inspectionNEAREST
department. do LOCALITY z� CROSS ST.
Date Applicant NEAREST �' f DISTRICT NO. I GROUP TYPE i PROCESSED BY
,CROSS ST. -^' CDNS Ty`/
CERTIFICATE OF EXEMPTION FROM WORKERS' C LEGAL }
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY CL
NO. (CIRCLE) STATE MAJOR SECOND LOCAL O
NO. OF SLOGS.
(This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) USE OF �.` LU
- SIZE OF LOT EXISTING BLDG. J
'I certify that in the performance of the work for which this LL
permit is issued, I shall not employ any person in any manner OWNER
yf"µ 'ms
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
MAIL
ADDRESS
Date Applicant
_ TEL. : ,�- ..
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD O
Exemption, you should become subject to the Workers' d
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: y`
W
With comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION N ❑
deemed revoked. o Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
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 PARKING.
effect. SPACES RED'D E= PROVIDED
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a: FROM: TO:
IIS licensed architect or a registered professional engineer SIZE OF NO, OF INS P CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I NATURE
iness and Professions Code). R`i SENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-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 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, 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). ,rI
JUrdPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY s .� ♦ a
I hereby affirm that there is a construction lending agency
fthe performance of the work for which this permit is 6
is ed(Sec. 3097,Civ.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address r t
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,
and hereby authorize representatives of this County to enter TOTAL FEE
upon thq above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date