HomeMy Public PortalAbout9670 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION I 76M444 MISCELLANEOUS
I C C E o L A A 1 E®II Y S A Its P p I C ii T I®A 1
CE 875(2-80) Irl .7 ` !1!V 14,J P1 Ir I� 0.�P'i tl
I Hereby affirmrt that I have a certificate of consent to self COUNTY OF LOS.ANGELES BUILDING AND SAFE'T'Y DIVISION
insure, or a certificate of Workers'Compensation Insurance,or' ����at""
a certified copy thereof(Sec.3800,Lab.C.) ( 2'..•
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDINGADDRESS J
(]670 Las Tunas LOCALITY
❑ Certified copy is filed with the county building inspection l e City NEAREST
Tem
department. I LOCALITY p y CROSS ST.
Date Applicant NEAREST Kauffman Av. DISTRICT NO. G U TYPgjf PRO(SfMED FLY
1 CROSS ST. d�i CONSV
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL IfOY
COMPENSATION INSURANCE I DESCRIPTION LOT NO. . BLOCK MAP f�/y �1/ HIGHWAY }
No. Cjp O / (CIRCLE)
STATE MAJOR SECOND LOCAL a
(This section need-not be completed if the work involved O. OF LOT one USE ZONE SPECIAL CONDITIONS Q
P TRACT NOW ON LOT
by the permit is for one hundred dollars ($100) or less.)i usE OF
EXISTING BLDG. y
em t
I certify that in'the performance of the work for which this i SIZE OF LOT
permit is issued I shall notPfaffttlenrma
y any person in any manner I ow ER Ronald Hanke O
so as t beco subject toorkers'Compensation n La AIL OCCUPANCY GROUP U
DDRESS 1593 Calle Candela vim-+ a
Date) Applicant 1� l� p f0)
NOTICE TO A PLICANT: king this Certificate of cI7YLa I Jolla 92037 N7.L14-459-8879 OCCUPANT LOAD z
Exemption, you should come subject to the Workers'i APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,'you must forth-
with comply with Such provisions Or this permit Shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. C1No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION ffX 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. REO'D � PROVIDED
SPACES
License Number Lic.Class
LIMITED TIME USE
,Contractor Date DATE. DATE
❑ PROM: TO:
I am exempt from the licensing requirements as I am a i
licensed architect or. a registered professional engineer' SIZE OF NO. OF ��11 INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 1775 STORIEso n SIGNATURE
iness and Professions Code). ' PRESENT USE OF BUILDING - FINAL APPROVAL fa''" �,r„.-�• LF `- ')
Lic,or Reg.No. Date CE
IG.• Y^ —+! �/
HOME OWNER-BUILDER DECLARATION No.of EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that, I am exempt from the Contractor's i
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED 2'673-A
❑ I, as owner of the property, will do the work and the 'f )
structure is not intended or offered for sale (Section `t'-5 #•0 0 0.0 8 8
7044, Business and Professions Code): 1
PROPOSED USE 6F.BUILOIN6 I
CONSTRUCTION LENDING AGENCY ! Window Coverings Retail
I hereby affirm that there is a construction lending agency , 1 9'-8 2
for the performance of the work for which this permit is i
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
I
Lender's Address 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 i ISSUANCE FEE
ordinances and State laws relating to build'ng constr ction,
a hereby authorize representative of th' County enter TOTAL FEE
pa the above-mention ope for ' spection rposes. I SEE REVERSE FOR EXPLANA ORY,LANGUAGE
I
a
lure o Permittee ;