HomeMy Public PortalAbout9831 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) MISCELLANEOUS APPLICATION
I hrreby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insule, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab.C). -
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished UILDING (y �
ADDRESS 7D LOCALITY
Certified copy is filed with the county building inspection LOCALITY
NEAREST
department. CROSS ST.
Date Applicant EAREST DISTRIC G OUP TYPE PROCESSED BY
CROSS ST. � NST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE I DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. F BLDGS.
HD. (CIRCLE) STATE MAJOR SEC- LOCAL
'
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. d
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner owNECW
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so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP p
Date Applicant vADDRESS t p '�I �J E3
NOTICE TO APPLICANT If, after making this Certificate of CITY . C v ITvo �, 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know].
deemed revoked. I
Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERM (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING REp'D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM' TO
licensed architect or a registered professional engineer SIZE OF No OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
inessand Professions Code)
FINAL APPROVAL
PRESENT USE OF BUILDING 0�1_Alll_Lic.or Reg No. Date
ro'&
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ;285 1.6A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code) NO. PARKING # • • • * 88
F1 I, as owner of the property, will do the work and the SPACES PROVIDED
En
structure is not intended or offered for sale (Section • • o o •,• o
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE-OF BUILDING d
1206 =87
I hereby affirm that there is a construction lending agency `\
for the performance of the work for'which this permit is a'� S _ U
issued(Sec. 3097,Civ.Q. �"\
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,
and hereby authoriz resentatives of this County to enter TOTAL FEE
above-me lone roperty for inspection purposes. `
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' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 1 Date