HomeMy Public PortalAbout9802 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
f hereby affirm that I have a certificate of consent tself CE 875(11.84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
ILDIN10
Policy No. Company FOR APPLICANT TO FILL IN BUADDRESSG OD/1
d �(
Certified copy is hereby furnished. BUILDING f�p�0 LAs an�S J�� LOCALITY
XX ADDRESS "%!dd (,/p�
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST e_ f DISTRICT Np, GRQUP TYPE P ESSED BY
CROSS ST. ®�G�I! A �D! CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (aJ
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO.OF BLDGS. NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOWON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG,
permit is issued, 1 shall not employ any person in any manner. OWNER Of buildin fAN ZL
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP14:1
ADOREss ,may O b r'
Date Applicant Z L f ' � u
NOTICE TO APPLICANT: If,after making this Certificate of CITY ', ,QQ To. OCCUPANT LOAD
Exemption, you should become subject to the Workers' V —
Compensation provisions of the Labor Code,you must forth- APP ICATIO OR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl.
deemed revoked. � Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION� ,�
I Hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT[] (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi- NO.OF EXITS
ness and Professions Code,and my license is in full force SIX Name of business 12/11 G Prnces ARKING
effect. Req'D PROVIDED
License Number Lic. Class
/, /� �/NIC.. s
LIMITED TIME USE
Contractor Date DATE DATE
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- EXISTING BLDG. STORIES SIGN TORE
iness and Professions Code). F1114AL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
. ; S:�:
LA
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1
ON LOT AND USE
I hereby affirm that lam exempt from the Contractor's h/ / [ f1 –(1F11,+1 � f i'•f'
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No.PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section'
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX.OCC.
Lender's Address
1 certify that I have read this application and state that the PERMIT FEE
95.00
above information is correct.I agree to comply with all County ISSUANCE FEE
' .ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25.00
upon the above-mentionedproperty for inspection purposes.
I ,� � 6 C' SEE REVERSE FOR EXPLANATORY LANGUAGE
XX XX �
Signature o Permittee Ilate