HomeMy Public PortalAbout9526 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 ������������ APPLICATION���I�/""� 1 �®1 tl
d hereby affirm that I Have a certificate of consentself CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insute� or a certificate of'Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING /
ADDRESS (/O_
F] Certified copy is hereby furnished. 6uILDING f�2 s-T �t'.
ADDRESS l LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DIS CT NQQQ. G OUP TYPE P ESSED BY
CROSS ST. �fJ [� _,� CONST. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v 0
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY'
NO. F BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
'
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT i 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 2 o
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP �
MAIL JJ Q ^ p
ADDRESS''7- _1 v v� lz�:] n
Date Applicant J
NOTICE TO APPLICANT: If, after making this Certificate of clr NOL � 2% IgS�O OCCUPANT LOAD
U-1Exemption, you should become subject to the Workers' APPLICA ION 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 and N e ��
effect. tv PARKING REQ'O PROVIDED
- SPACES LL��J
License Number Lie. Class Joh , f..6—Li SPACES
TIME USE
Contractor Date DATE DATE
D I am exempt from the licensing requirements as I am a
FROM: TO:
licensed architect or a registered professional engineer slzE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG, STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL _
PRESENT USE OF BUILDING v+-r'
Lie.or Reg.No. Date Z {_ OO
1y� a
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS i = 5 r� EE
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 --; ;;; i, ; ;C .
nJen
ss and Professions Code): NO. PARKING -- - -
SPACES PROVIDED [�
I, as owner of the property, will do the work and the =1!ii L ; ,• 4:17
structure is not intended or offered for sale (Section
7044,Business and Professions Code). IA
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
hereby affirm that there is a construction lending agency /I}
r the performance of the work for which this permit is I
ued(Sec. 3097,Civ.C.).
nder's Name
PROPOSED MAX. OCC.
der's Address
certify that I have read this application and state that the PERMIT FEE �.
ove information is correct.I agree to comply with all County ISSUANCE FEE
dinances and State laws relating to building construction,
d hereby authorize representatives of this County to enter TOTAL, FEE
on the abov -mentioned property for inspection purposes.
�
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date 1