HomeMy Public PortalAbout9810 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hxreby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES tJILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANTTO FILL IN BUILDING
AD I7 R E S5 6l//
❑ Certified copy is hereby furnished. ncuREss I,/–'S —� �S L" LOCALITY
❑ Certified copy is filed with the county building inspection NEAREST
department. LocaLlry �� t3 Q� CROSS ST.
Date Applicant XHAREST DIST �Tfi O. GROUP TYPE PRO ESSED BY
CROSS ST. �/�� (J��� /Jlyy �� CONS'ET./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V
DESCRIPTION LOT NO. .BLOCK
COMPENSATION INSURANCE NOP HIGHWAY
STATE MAJOR SECOND LOCAL d
NO. OR BLDGS.
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE rIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. 0C
I certify that in the performance of the work for which thisT _ Q
permit is issued, I shall not employ any person in any manner NER xis I 0� V
so as to become subject to the Workers' Compensation Laws. /'� r w OCCUPANCY GROUP
MAD RLLI
ESS i�0 1 I`/.?/�J
Date Applicant f
1 ,, L Z
NOTICE TO APPLICANT: If, after making this Certificate of CITY A.' -C/1JL,&.-- o. �8� 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 SAFETY PERMIT ❑ (LIST ITEMS BELOW) I NO. OF EXITS El9 (commencing with'Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. REQ'D PROVIDED
SP ASC ES
.License Number Lic.Class
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 S TORE
iness and Professions Code). T USE OF BUILDING FINAL APPROVAL �1
RESEN
Lic.or Reg.No. Date +°
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- 2 f a
nese and Professions Code): NO.PARKING lj y 1 ! Q
SPACES PROVIDED
❑ I, as owner of the property, will do vJ the work and the I 4 r��� I
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
PROPOSED USE OF BUILDING
09 A
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.
I
Lender's Address PERMIT FEE
I certify that 1 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,
and hereby authorize representatives of this County to enter TOTAL FEE -.17
I
upon theaentioned property for i oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date