HomeMy Public PortalAbout9425 LAS TUNAS DR_Miscellaneous__ i WORKERS' COMPENSATION DECLARATION 76M20-0063DPW12l90 MISCELLANEOUS APPLICATION
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I hereby affirm that I have.a certificate of consent to self COUNTY OF LOS ANGELES BUILDING:.AND SAFETY DIVISION 1`
( I ;insure,or a certificate of:Workers'Compensation Insurance, or
a certified copy thereof (Sec. 3500, Lab.C.)•
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
=- -
BUILDING ADDRESS - ADDRESS
❑ Certified copy.is hereby:furnished. g LOCALITY
❑ Certified copy is filed with the county building inspection CITY ZIP f
department. c_t' 1 NEAREST
CROSS ST.
Date '• - - Applicant SIZE OF LOT �c NO.OF BLDGS.NOW ON LOT DISTRICT No. GROUP TYPE PROCESSED BY C
-3 o,6®OCONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. `
COMPENSATION INSURANCE MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL..
(This Section need not be completed if the work involved ASSESSOR MAP BOOK PAGE .PARCEL
USE ZONE SPECIAL CONDITIONS
� by the permit is for one hundred dollars ($100) or, less.)
r I.certify that in the performance.of the work for which this —�rfy: ei
n TEL O.
permit is issued:I.shall not employ any person in any manner
t a A 2 -ryd o N u u
so as to become subject to the Workers' Compensation Laws. ADORESS��_ OCCUPANCY GROUP �� v
Date Applicant CITY ZIP �J
NOTICE TO APPLICANT: If. after making this Certificate I OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE:
comply With such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑
l- revoked. No Spec.Knowl. ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION[ Panic Devices ❑
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I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) E]4 i 9(commencing with Section 7000)of Division 3 of the Business ame o uslness NO,OF EXITS
3 and Professions Code,and my license is in full force and effect.
PARKING• REO'D I 1 PROVIDED
License Number Lic. Class 7` wve1c eI� S•erocee 1tn SPACES LJ
t 1 Contractor Date LIMITED TIME USE
❑ I am exempt from the licensing requirements as I am a DATE DATE
licensed architect or a registered professional engineer FROM: To:
acting in my professional capacity(Section 7051, Business SIZE OF NO.OF INSPECTOR'
S EXISTING BLDG. STORIES SIGNATU
and Professions Code).
PRESENT USE OF BUILDING
Lic. or Reg. No. Date FINAL APPROVAL
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, Business and
d I Professions Code): NO.PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING
Business and Professions Code).
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.). PROPOSED MAX.OCC.
Lender's Name APP (CANT(PRINT) /�/) TEL
NO, Q
LendeI's Address ADDRESS C�0 /.H��1ppIY` 9 //
t I certify that I have read this application and state that the w S '`t/"50n ctrle/I
above information is correct. I agree to comply with allCounty PERMIT FEE
ordinances and State laws relating to building construction,and
hereby authorize representatives.of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes. .
_ TOTAL FEE - -
% 5 _ 5 -O? SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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