Loading...
HomeMy Public PortalAbout9675 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION bE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company I FOR APPLICANT TO FILL IN BUILDING ElADDRESS f ��Jy 7Y Certified copy is hereby furnished. BUILDING / LOCALITYd. ADDRESS ❑ Certified copy is,filed.with the county building inspectio I Y14 .1 NEAREST department. LOCALITY CROSS ST. P"4 � Date Applicant NEAREST DISTRICT O. ?��JTYI. PRO SED BY CROSS ST. Dom/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE �� NO. © (CIRCLE) STATE MAJOR SECOND L cAL Q. NO. OF BLDGS. (This section need not be completed if the work involved TRACT �S NOW ON LOT USE ZONE SP CIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE of _ SIZE OP LOT EXISTING BLDG. I certify that in the performance of the work for which this p permit is issued, I shall not employ any person in any manner 11 owNER U so as to become subject to the Workers' Compensation Laws: MAIL / OCCUPANCY GROUP W ADDRESS t t l O Sf' CL Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of clrY G. •}y. N lL ( & /Z—O 1G j OCCUPANT LOAD Exemption, you should become 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❑ No Spec. Knowl. ❑ deemed revoked. t Panic Devices ❑ LICENSED CONTRACTORS DECLARATION occuPANcv INSPECTION I hereby affirm that I am licensed under provisions of Chapter i SAFETY PERMIT q (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 effect. PARKINI. REQ'D O PROVIDED D i SPACES License Number Lic.Class . I � LIMITED TIME USE Contractor Date DATE DATE Eli FROM: ' TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional ,engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- ISTING BLDG. STORIES IG NATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL _ 0 Aut Lic.or Reg.No. Date r HOME_OWNER-BUILDER DECLARATION NO.OF EXISTING B ILDINGS ON LOT AND USE A 1 19. ' # O O O O A A 8 ' I hereby affirm that, I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- . 0 a 0 Hess and Professions Code): NO. PARKING f 2.0 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). ! POSED USE OF BUILDING CONSTRUCTION LENDING AGENCY / I hereby affirm that there is a construction lending agency Ti ' 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 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 ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter �up-,o`n th�beve-meenntioned p perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ! S} e o eriWee ate r i