HomeMy Public PortalAbout9449 1/4 LAS TUNAS DR_Miscellaneous__ WORKLRS' COMPLNSAIION DECLARATION 'um-111 MISCELLANEOUS APPLICATION
20-006::DPW 12'90
I hereby affirm that I have it certificate of consem to sellCOUN'FY OF LOS ANGELES BUILDING AND,SAFETY DIVISION
insure,or a certificate of Workers' Compensation Insurance. or
a certified copy thereof (Sec. 3800, Lab. C.)
d Policy No. _ Company FOR APPLICANT TO FILL IN BUILDING
- BUILDING DgRESS �; C T ADDRESS
M t-
❑ Certified copy is hereby furnished. �lLll � L,�y' /-09Vg f D/` P LOCALITY
1 ❑ Certified copy is filed With the county building inspcction EITY ,zip
department. 72Ly _ C/T �� c? 7A o NEAREST
CROSS ST.
Date -__ Applicant F fC1T - NO.OF BLDG- NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
CONST. {'
CERTIFICAlI: OF EXEMPTION FROM WORKERS TRACT' BLOCK LOTNO.�{{
C'OMPLNSAIION INSURANCE 1 MAF HIGHWAY .
NO. ICIRCLEI STATE MAJOR SECOND LOCAL
(This section need not be completed if the Work iltvlllYed ASSESSOR MAP BOOK PAGE PARCEL
USEZONE SPECIAL CONDITIONS
� by the permit is for one hundred dollars 0+10111 or le,s.)
OWNER TEL NO. )•
1 certify that in the performance ol' file work for whicil this T� i ( C' 1 r ----
permit Is issued. I shall not employ any person in any manner
I I.
so as to become subject to the Workers' Compewation Laws. ADDRESS! 141q OCCUPANCY GROUP r"
- %..
Date Applicant clT ZIP -
NOTICE TO APPLICANT: If, after making this Certificate Q OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,YOU must fowiwith 7
comply With Such provisions or this permit Sltalll be deelnCd TRAILER USE El GEOLOGY INSPECTION 0
I revoked. y No Spec.Knowl. ❑
OCCUPANCY INSPECTIONIK Panic Devices ❑
LICENSED CONTRACTORS DECI_ARNHON
c I : hereby affirm that I ain licensed under provisions of Chapter SAFETY PERMIT❑ ILIST ITEMS BELOW I
1 I 9(commencing with Section 7000)of Division 3 Of the Business NO.OF EXITSEl
and Professions Code,and my license is in full force and effect. tt��
I hiAMc CS! lit-\„{NIcS�`j PARKING•
i License Number Lie. Class - „/ CD R u�r /h /' SPACES REQ'D PROVIDED C�
" --I--�—r --- - ---------- - - ---- - LIMITED TIME USE
Contractor Date -- ------
I - DATE DATE
❑ 1 am exempt from the licensing requirements as I and a FROM: TO:
licensed architect or a registered professional engineer
J jNO.OF
acting in my professional capacity (Section 705I, Ilusiness SIZE OF INSPECTOR'S
and Professions C IYde). EXIS LING dLUG. STORIES -� - _ SIGNATURE -
Lic. or Reg. No. Date PRESENT USE OF BUILDING !FINAL APPROVAL %�j O(
---
,VEW foil p
HOME OWN!'[;-BUILDER DECLARAI ION NO OF EXIST INC.BUILDINGS
I ON LOT AND USE
hereby affirm that I and exempt front the Contractor's Li_ensc -� r
Law for the following reason (Section 7031.5, Business and
i Professions Code): NO.PARKING
SPACES PROVIDED
❑ 1. as owner of elle proper)\'. \rill do the {cook an11 thr — -- - ---------,I
Structure IS Ilol Intended ill' UlleI CII fUl Salle (Section Illi4, PROPOSED USE OF BUILDING
Business and Professions Code).
;_I � G�irr®u,�j►�,��dc:rrld g S.e�-�/��is ;'
CONSTRUCTION LENDING AGENCY
hereby affirm that there is it construction lending agent:) for
the performance of the work for \%hich this permit is issued -- -- Y
�) (SCC. 3097,CIV. C.), PROPOSED MAX.OCC. j
Lenders Name __..________.__--__.;__.. . .. . ... ...._----. .. APPLICANT(PRINT) EL
X S Ckdw- MA L<
Lender's Address - ADDRESS q
I certify that I have read this application and stale that the l3 l/ la
•� above information is correct. I agree to comply with all County 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 r y tt inspection purposes.
%moi. I - TOTAL FEE
� V10
n
o SEE REVERSE FOR EXPLANATORY LANGUAGE
In
Signa ure of f4rinittee ne
I
y