HomeMy Public PortalAbout9678 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. ABUILDINGDDRESS SS r v��� . LOCALITY !
ADDRESS G
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY e /.1 CROSS ST.
Date Applicant NEAREST v DISTRICT NO. G P T1 pit
PROC SSED B
CROSS ST. /7 gig, Y�'CONST. /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWA; }
NO. (CIRCLE' STATE MAJOR SECOND LOCAL d
(This Section need not be completed if the work involved NO. OF BLDGS. USE ZONE SPECIAL CONDITIONS
P TRACT NOW ON LOT D
by the permit is for one hundred dollars ($100) or less.) U
USE OF
SIZE OF LOT EXISTING BLDG. / tr
I certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner WNE f
so as to become subject to the Workers' Compensation Laws. AIL _ OCCUPANCY GROUP
W
IU
ADDRESS
Date Applicant to
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of Z
clry CL No. G OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPL CATION 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. ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Q/
Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS a
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. PARKING.
SPACES REq'D D PROVIDED D
License Number Lia Class LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a
om:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). - RESENTFINAL APPROVAL USE OF BUILDING � �.
Lic.or Reg.No. Date6L
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's z 3 7 2 7 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED # • • • g g
❑ 1,.as owner of the property, will do the work and the
structure is not intended or offered for sale (Section O !S ! }t }t z
7044, Business and Professions Code). C 9 L
ROPOSED USE OF BUILDING
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.).
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. 1 agree to comply with all County ISSUANCE FEE T
ordinances and State laws relating to building construction, TOTAL FEE ,/ /
and hereby authorize representatives of this County to enter i0� (J'
U o he abo -mentioned property f r inspectises. SEE REVERSE FOR EXPLANATORY7A�NGUAGE
Signature o ttee Date