HomeMy Public PortalAbout9178 LAS TUNAS DR_Miscellaneous__ ( I WORKERS' COMPENSATION DECLARATION 2I
000 3DPw;ziso 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
BUIL IN ADDRESS ADDRESS
❑ Certified copy is hereby furnished x J LOCALITY
❑ Certified copy is filed with the county building inspection CIT ZIP
t department 11 �� CROSS ST
' Date - Applicant SIZE LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPEPROCESSED BY
CONST
CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO
i COMPENSATION INSURANCE MAP - HIGHWAY
No (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (S100) or less.)
] erfy Uum
i I certify that in the performance of the work for which this 25/z TEL NO �d /
permit is issued. I shall not employ any person in any manner t '
so as to become subject to the Workers' Compensation Laws AD Ess i
OCCUPANCY GROUP
( Date Applicant CITY ZIP
NOTICE TO APPLICANT If. after making this Certificate OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE
( comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Know[ ❑
revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) a
r I 9(commencing with Section 7000)of Division 3 of the Business NO OF EXITS
and Professions Code,and my license is in full force and effect ame of Busmess
PARKING• REO'D [== PROVIDED D
License Number Lic Class f SPACES
t i I Contractor Date LIMITED TIME USE
DATE DATE
1 ❑ 1 am exempt from the licensing requirements as I am a FROM TO'
licensed architect or a registered professional engineer
t acting in my professional capacity (Section 7051, Business E ISTs1zEOING BLDG sroRies INSPECTOR'S
SIGNATURE.
and Professions Code)
Lic. or Reg. No - Date PRESENT USE OF BUILDING FINAL APPROVAL
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 70315, Business and
I Professions Code)- NO PARKING
❑ has owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale(Section 7044,1 PROPOSED USE OF BUILDING
Business and Professions Code)
( � I
CONSTRUCTION LENDING AGENCY
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.) PROPOSED MAX OCC
Lender's Name APPLIC r wr
Lender's Address ADDRESS
I certify that I have read this application and state that the
above information is correct I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building construction,and
hereby author representatives oft s County to enter upon ISSUANCE FEE
the abov tinned property f r i pection purposes.
TOTAL FEE
° % / t v SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Slenature of Pennittee Date