HomeMy Public PortalAbout9510 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFE'T'Y DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.'C.) ,
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. uILD ISG .5/U/) % LOCALITY
DRESS L. - a
Certified copy is.filed with the county building inspection NEAREST
department. LOCALITY p I'' CROSS ST.
Date Applicant NEAREST / DISTRICT NO. UP TYPE P CESSED BY
CROSS ST. CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL y
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 07 HIGHWAY
No. (CIRCLE) STATE MAJOR'SECOND LOCAL
NO. OF BLDGS. 0-
(This Section need. not be completed if the work involved TRACT NOW ON LOT USE ZONE d
by the permit is for one hundred dollars ($100) or less.) 1_S!J!!7CONDITiONS
0
- - USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance'of the work for which this .
permit is issued, I shall not employ any person in any manner OWNER j�
so as to become subject to the Workers' Compensation Laws. AIL //� ^L� yp ,�,{i� r r OCCUPANCY GROUP =,z
o
DRESS /a! I` V 'L-/ , f LU
Date Applicant C
NOTICE TO APPLICANT: If, after making this Certificate of TY�& Aart' NO. � �j OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,-you must forth- ll��l
with comply with such .provisions or this permit shall be. TRAILER USE❑ GEOLOGY INSPECTION❑ NO Spec. Knowl. LJ
deemed revoked. a
S
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
- ❑
I'tereby 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-- rvo. of EXITS
ry,ss and Professions Code, and my license is in full force and PARKING.
effect. SPACES REO'D PROVIDED
License Number Lic.Class LIMITED TIME USE �J
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a: FROM: TO:
licensed architect or a,registered professional engineer. SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, BUS- XISTING BLDG. STORIES SIGNATURE
iness and Professions Code). RESENT USE OF BUILDING I / FINAL APPROVAL
Lic.or Reg.No. Date"
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS r 0`172
2 0 p
ON LOT AND USE
I hereby affirm that, I am -exempt from the Contractor's f olo 0 o P F?
License Law for the following reason.(Section .7031.5, Busi- U
o.'0 0 0 0 0 0 '
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).
OPOSED USE OF BUILDING 1 re,
CONSTRUCTION•LENDING AGENCY 1
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 - -
I certify 'that I have read this application and state that the
above information is correct. Lagree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
a d hereby authorize representatives of this County to enter
Aon the above-menti edp erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date