HomeMy Public PortalAbout9174 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875 L )
I hertby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 'DLIII
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(See 3800,Lab C.)
Policy.Nc%. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy,is hereby furnished. BUILDING Las
_ a � r. LOCALITY
.DDR.
L.
SS GI '/
❑ Certified copy is filed with the county building inspectionLOCALITY NEAREST
department. X c 1 CROSS ST
Date Applicant NEAREST DISTRICT NO I GROUP TYPE CESSED BY
CROSS ST. �O �j -� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a f
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. F BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved TRACT NOWOON 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 LOT EXISTING BLDG. ` o
permit is issued, I shall not employ any person in any manner OWNER ='
so as to become subject to the Workers' Compensation Laws MAIL ���/ Ave i OCCUPANCY GROUP
a a
ADDRESS b (.`� ~
Date Applicant / L��
NOTICE TO APPLICANT. If, after making this Certificate of CITY QigroL �� " Op OCCUPANT LOAD
Exemption, you should: become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth- El comply with such provisions Or tills permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
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
effect. }� A�I7P�� ALI PARKING
SPACES REp'D D PROVIDED D
License Number Lic ClassAdvance r i- w
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
"ROM' TO
licensed architect or a registered professional engineer SIZE OF NO OF INSPECTORS
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No Date vex-can (' Z
HOME OWNER-BUILDER DECLARATION NO OF EXISTING buILDINGS ' I:_71 -1,'i li t': 'i=•I:
ON LOT AND USE '
I hereby affirm that I am exempt from the Contractor's \� fj ��' 1 rAN t
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code)- NO PARKING
❑ I, 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 PROPOSED USE OF BUILDING r/
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
above ulformatio is correct I agree to comply with all County ISSUANCE FEE
ordinances an tate laws re to building construction,
and he y a orize represe t Ives of tills County to enter TOTAL FEE
upon 1 abo mentio p rty for lnspectto pui oses
f fI SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee / Date