HomeMy Public PortalAbout9529 1/2 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS
CE 875 (2-80) APPLICATION
LICr1TI®N
I hereby affirm that I have a certificate of consent to self COUNTY.'OF LOS ANGELES' BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a�crtified copy thereof(Sec. 3800,,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS A
❑ Certified copy is hereby furnished. UIL%NG Z G ..� LOCALITY
ADDRESS -
❑
Certified copy is filed with the county building inspection to /] NEAREsr
department. LOCALITY /i / cRosS ST.•
.Date Applicant N EST K DISTRICT NO. G OUPTY PE PRO S ED BY
ROSS ST. $' ` �(•/ ��7 CONST, / -
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL IJX L_ AY/
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP RIGRWAY
NO. (CIRCLE)_ STATE MAJOR SEC D LOCAL a
_ NO. OF BLDGS. O
(This seC,tlOn need not be completed if the Work involved TRACT ' NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars`($100) orless.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner ER
so as to become subject to the Workers''Compensation Laws. J;?
'u' yy _ OCCUPANCY GROUP W
DRES S,457 tZ
Date Applicant
NOTICE,TO APPLICANT: If, after making this Certificate of clrv� �dPT eG�E,�� �-1p�9S 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
deemed revoked. ❑ No Spec. Known. ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices.. El
I hereby affirm that I'am licensed under provisions of Chapter SAFETY PER ❑ (LIST ITEMS BELOW) No.OF Exlrs
❑
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. PARKINGSPACES REO'D O 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 ND. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE.
iness and Professions Code). P SENT USE of BUILDING FINAL APPROVAL
Lic.or Reg:No. Date '
HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS
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- . �,3 9 6 3 A
ness'and Professions Code): NO. PARKING
SPACES,PROVIDED - -
❑ I, as'owner of the property, will do the work.and the # o o 'o'o 8 8
structure. is not intended or offered for sale (Section
7044, Business and Professions Code).
POSED USE OF BEn
UILDING '� 11� •e �� 1 s�g
CONSTRUCTION LENDING AGENCY
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 n 0'v
above information is correct. I agree to comply with all County ISSUANCE FEE 0�
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter, TOTAL FEE
upon the above-mentioned proper y for inspectio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ture of Permittee Date