HomeMy Public PortalAbout9436 LAS TUNAS DR_Miscellaneous__ \VORKERS'COMPENSATION DECLARATION CE 8754(11.84) M ISCLL ANEOUS APPLICATION
I hereby affirm that 1 have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
BUILDING
Policy No.—_ Company FOR APPLICANT TO FILL IN t5 / �J
ADDRESS 7T Cv
FICertified copy is hereby furnished. BUILDING � //� 1' LOCALITY
XX ADDRESS \ (Q Vk t2•
FCertified copy is filed with the county building inspection LOCALITY n�� NEAREST
department. 3txj �+l ceoss sr.
Date _Applicant NEAREST - DISTRICT NO. GROyI/�P CONST. MESSED BY
CROSS ST. DIP /'�. ITYPE
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /4 C /
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
NOOF BLDGS.
(This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USEOF
SIZE OF LOT EX Is TING BLDG.
1 certify that in the performance of the work for which this c�
permit is issued, I shall not employ any person in any manneXX OWNER of buildin RE irk ✓1
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP R_
CJ
ADDRESS U
Date_ Applicant L,
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. 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. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
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 ar*X
effect. Name of business PARKING SPACES REG'D E= PROVIDED
License Number Lic. Class ToYr— CF,
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO: �
El am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer.,, SIZE OF NO.OF INSPECT R S
acting in my professional capacity (Section 7051, Bus=•1' EXISTING BLDG. STORIES SIGNA uRE
iness and Professions Code)
yrs PR ESEN'T USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date f z . ID`
i
HOME OWNER-131JILDER DECLARATION 2 1: ANO. OF EXISTING BUILDINGS / , ,�7 ✓1;� �,
to '+ ON LOT AND USE rv/
hereby affirm that I ant exempt from the ,Contrai.t i s
License Law for the following reason (Section 7031.5 Busi
ness and Professions Code): • NO. PARKING
SPACES PROVIDED ,
1, as owner of the property, will do the work and Ahe'
structure is not intended or offered for sale (Seciion(, n
7044,Business and Professions Code). .4 `,-
CONSTRUCTION LENDING AGENCY "� PROPOSED USEOFBUILDING
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.). h sa
Lender's Name !
PROPOSED MAX. OCC.
Lender's Address__ __.
PERMIT FEE25 . 00
'
I certify that I have read this application and state that the
above information is correct. 1 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 abo a-ment oned property for inspection purposes.
EE REVERSE FOR EXPLANATORY LANGUAGE
XX XX
Signa ore of Ilernlittee Date