HomeMy Public PortalAbout9225, 9225 1/2 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 BUILDIN SAF Y DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof•(Sec 3800,Lab C)
Policy Notes c6B�mpany _S�& RC1 o,H�i�i�1�s FOR APPLICANT TO FILL IN IN
UILDING
DDRESS
❑ Certified copy is hereby furnished BUILDING OCALITY
ADDRESS f
❑ Certified copy is filed with t e c uildm I pection EAREST
department LOCALITY ROSS ST
Date Z— �P� Applicant NEAREST ISTRICT NO ROUP T P ;P�S ED BY
CROSS ST CONST
CERTIFICATE OF EXEMPTI FROM WORKERS' LEGAL ✓
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NOP (CIRCLE) }
( ) STATE MAJOR SECOND LOCAL d
NO OF BLDGS O
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) U
USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this O
permit Is Issued, I shall not employ any person in any manner OWNER ` , I—
so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP
Ez-:2:1
U
LU
ADDRESS `� 8 L � LI
Date Applicant
NOTICE TO APPLICANT If, after making this Certificate of cITY N0L / — _ 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
deemed revoked. ❑ ❑ No 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
❑
I (commencing with Section 7000) of Division 3 of the Busi-
cess and Professions Code, and my license is in full force and PARKIN
efffect SPACESG REO'D PROVIDED
Lticense Number Llc Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF rvo of INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
iness and Professions Code) /i / N• FINAL APPROVAL �y/i
PRESENT USE OF BUILDING /r as `
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) PROPOSED USE OF BUILDING /
CONSTRUCTION LENDING AGENCY Q
I hereby affirm that there is a construction lending agency .d u ✓J
for the performance of the work for wh)ch this permit is
issued (Sec 3097,Civ C)
Lender's Name
PROPOSED MAX OCC
Lender's Address PERMIT FEE
I certify that 1 — read t application and state that the
above rm on is c r t I gree to omp y with all County ISSUANCE FEE
of
antes i State ws r sting t buil ing construction, TOTAL FEE
an hereby thoriz epre ntatives f t s County to enter
u on the ove- one property or spection purposes SEE RFVERSE FOR EXPLANATORY LANGUAGE
Signature of P mittee Date