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HomeMy Public PortalAbout9464 LAS TUNAS DR_Miscellaneous__ } I MISCELLANEOUS /Q WORKEWF'COMPENSATION DECLARATION CE 876(2-80) tl`►tl ��� �A�I lJ S APPLICATION I hereby affirm that I have certificate: of consent sell' COUNTY OF LOS ANGELES BUILDING.AND SAFETY DIVISION insure, or a certificate�ot Workers' rs'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. ADUILDING DRESS LOCALITY ❑ Certified copy is filed with the county building inspection NAL FS EAREST department. LOCALITY . CROSS ST. Date Applicant AREST // DIST CT�O/ OUP TYP / PRO SED BY CROSS ST. L... &� S ® !1 J�/1/ CO T.n/ CERTIFICATE OF EXEMPTION FROM WORKERS' LE�nL VV �/A 111/// DESCRIPTION LOT NO. BLOCK '. COMPENSATION INSURANCE "'AP "'�"WAY No. (CIRCLE) STATE MAJOR SEC D LOCAL d NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONT NS O by the permit is for one hundred dollars ($100) or less.) • SIZE OF LOT EXISTING BLDG. C_Z1 I=' 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. OWNERAVADISI— so as to become subject to the Workers' Compensation Laws. AIL h • ONIA OCCUPANCY GROUP v W ADDRESS V , l '� , N Date Applicant z NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL y.— ,;L OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- I�/ APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION deemed revoked. ❑ No Spec..Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 force and PARKING effect' SPACES REO'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as I am a: licensed architect or a, registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 705.1, Bus= EXISTING BLDG. 1.5TORIES NATURE iness and Professions Code). ESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date C o i , / L A u n+ ^R HOME OWNER-BUILDER DECLARATION NO.of ANDEXISTING BUILDINGS Y 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 )' SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). R OPOSED USE OF BUILDING p'�= U ;/4 6 C A n CONSTRUCTION LENDING AGENCY co ( �' / /J(( 4 J 7 /1 I hereby affirm that there is a construction lending agency !/` # 0'0.0 ® 88 for the performance of the work for.which this permit is issued(Sec. 3097,Civ.C.). © 0 0 0 0 o s z Lender's Name PROPOSED MAX. OCC. 0519-86 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, TOTAL FEE and hereby authorize representatives of this County to enter Apon the above-mentioned property for inspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE _ o' 4.�:�a�ns z riot 1/S"1��(�. - - • Signature of Permittee Date