HomeMy Public PortalAbout9228 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENEAT-ION-Dr CLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N
I hereby affirm that I have a certlf ee of consent to self CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a ceptificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C).
Policy No Company BUILDING
FOR APPLICANT TO FILL IN T vE
ADDRESS
Certified copy is hereby furnished BUILDING
ADDRESS 8228 LaS Tunas Dr. LOCALITY
D Certified copy is filed with the county building inspectiow7x LOCALITY
NEAREST
department. CROSS ST.
Date Applicant NEAREST TYPE PR SSE BY
CROSS ST or A` `!� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ��J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO OF BLDGS.
NO (CIRCLE) STATE MAJOR SECOND LOCAL
(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.) .
USE OF
SIZE OF LOT EXISTING BLDG.
I certify that m the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNERDE & =-D
so as to become subject to the Workers' Compensation LawsMAIL OCCUPANCY GROUP cc
ADDRESS (3 V
Date Applicant l
NOTICE TO APPLICANT• If, after making this Certificate of CITY
TEL
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 ❑
deemed revoked ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERM T ❑ LIST ITEMS BELOW NO OF EXITS
ness and Professions Code, and my license is in full force and
effect, PARKING REQ'D PROVIDED
SPACES
License Number Lie Class Rea 1 tV Worlrl — PaCific Dynasty LIMITED TIME USE
Contractor Date DATE DATE
F1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM TO' AP E
PE CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATURE
mess and Professions Code). 100% FINAL APPROVAL
PRESENT USE OF BUILDING
Lie or Reg.No. Date -A G1 I
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- N113 FEE
ness and Professions Code) NO. PARKING
ElI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section 9[iCor000i 7/ 1/90
7044,Business and Professions Code) pM {
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 471] 1 r71111�1�4
I hereby affirm that there is a construction lending agenc and other rel
for the performance of the work for which this permit is Real nffir-p
ated
issued(Sec 3097,Civ C.).
Lender's Name
PROPOSED MAX OCC
Lender's Address
PERMIT FEE 60�
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, _n
and hereby authorize representatives of this County to enter TOTAL FEE n
u n the above-mentioned property for i A
pection pure ses f
/J SEE REVERSE FOR EXPLANATORY LANGUAGE
(� d
Si ature of Permittee Date