HomeMy Public PortalAbout9835 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION F, 76M444 MISCELLANEOUS APPLICATION
CE 875 (2-80)
I thereby affirm that I have a certificate of consent to selfLOS ANGELES
,')Insure, or a certificate of Workers'Compensation Insurance,or COUNTY,OF' BUILDING AND SAFETY DIVISION'.
',.a certified copy thereof'(Sec 3800,Lab C)
'Policy No Company FOR APPLICANT TO FILL IN BUILDING
- ,,,.'- _ �j• ADDRESS
O
E Certified copy is hereby furnished BUILDING -"'' j�• L`OCALITY
• �.
ADDRESS
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Certified copy is filed with the county building inspection
"iNEAREST li,
'OI LOCALITY // .✓
department CROSS ST
;,Date Applicant' ''' L EAREST . `• DISTRICT NO I GqR 1,P-� TYPE PROC SED BY
t � J CROSS ST Y �q• )ter CONST, a
CERTIFICATE,OF EXEMPTION FROM WORKERS' LEGAL,' Yh 7/- y" ���^ O
COMPENSATION INSURANCE DESCRIPTioN LOT No. BLOCK MAPI HIGHWAY U
^'` 4a No '�•'��"� (CIRCLE) STATE MAJOR SECOND LOCAL W
"'I
I NO OF BLDGS ,
(This section need-not be completed if the work involved TRACT NOW ON LOT B USE ZONE SPECIAL CONDITIONS J
'by 'the permit is for one hundred dollars ($100) or less.) _T 7 Ii
USE OF
SIZE OF LOT EXISTING BLDG w} C,•„/y�
certify that m the performance of the work for which'this 5„f ,
permit is issued, I shall not employ any person in any manner OWNER R , Q
so as to become subject to the Workers' Compensation Laws .MAIL OCCUPANCY GROUP r
'S. ADDRESS• d
Date` Applicant
NOTICE TO;APPLICANT_If,'after making this Certificate of 'CITY a r
NO. OCCUPANT LOAD W
Exemption,' you should become subject 'to ,the Workers' p ppLICATION 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 Q NO Spec. Knowl. O
deemed revoked i ❑
J OCCUPANCY-INSPECTION
Panic Devices
LICENSED CONTRACTORS DECLARATION t' i
I hereby affirm that'I am licensed under provisions of Chapter 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 forcetand x
effect.- SPACESG' REO'D E= PROVIDED
License Number Lrc Class c t
,r ri LIMITED TIME USE
Contractor Date DATE DATE
= V 11 FROM TO
E, I am exempt from the licensing.requirements as I am a
licensed architect or a registered professional engineer_. SIZE OF NO OF INSPEcroR's
acting in my professional capacity (Section 7051, BUS- >> EXISTING BLDG STORIES SIGNATURE
In CSS and PI'OfCSS10I15 Code) PRESENT USE OF BUILDING FINAL APPROVAL '
Lic or Reg No Date m
` OWNER-BUILDER DECLARATION No. of EXISTINY. BUILDINcs
HOME,
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-
ness and Professions Code) No PARKING ;m la io a p
SPACES PROVIDED _
I, as 'owner of the p ro erty, will do the work and,.thee'e Iy •,0. 10
:a structure is not intended 'or offered for sale (Section
7044, Business and Professions Code) , I
ROPOSED;U SE OF BUILDING -
•
CONSTRUCTION LENDING LENDING AGENCY, s
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 "
L,certify that I•have read this application and state that thet
V ISSUANCE FEE
above mformatwn'is correct- I agree to comply with all County - - - -
ordinances,and State laws relating to building construction,] g
and thereby authorize representatives of this County to enter TOTAL FEES '
upon,the attbove-mentioned property foi inspection'purposes ' SEE REVERSE FOR EXPLANATORY LANGUAGE ' ,
Signature of Aeimlttee Date '