HomeMy Public PortalAbout9565 LAS TUNAS DR_Miscellaneous__ WOE ERS'COMPENSATIQ'i, DF'i^LAF ATION 76M444
a CE 875(11-84) MISCELLANEOUS APPLICATION {�
I Aereby.affirm that I have a cerfic rofeconsent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Ll
instlfe;or a certifica-te of Workers'Compensation rnsurance,or
a certified Eopy thereof(Sec. 3800,Lab.C.).
BUILDING
Policy No. Company FOR APPLICANT TO FI LL IN
ADDRESS
FICertified copy is hereby furnished. BUILDING LOCALITY_`^ _aJ7J
ADDRESS
SS
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. Le C'i7 � CROSS ST.
Date Applicant NEAREST } / DISTRIC NO.- RO� TYPE OCES ED BY
CROSS ST. L,g + y /� 5 J(/ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
r+o. (CIRCLE) STATE MAJOR SE CON LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLDG. d
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any mannertMAIL
WNER
so as to become subject to the Workers' Compensation Laws. ¢ Q� OCCUPANCY GROUP o
�/ w A DDRESS L U (� '—Date ApplicantNOTICE TO APPLICANT: If, after making this Certificate ofITY �Nd 9Z-Z OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATI N 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 occuawNCY INSPECTIOPanic Devices
N
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
effect. PARKING SPACES REQ'D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
D /Y FROM: TO:
I am exempt from the licensing requirements as I am a (i v
licensed architect or a registered professional engineer SIZE OF NO. OF S GNATUR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL �
Lic.or Reg.No. Date I
T /L
HOME OWNER BUILDER DECLARATION NO. of EXISTING BUILDI GS 1 E
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 1300_l—!31i]111 1/213/90
I, as owner of the property, will do the work and the SPACES PROVIDED 8436 1 AMii'eC `
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
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 nn
PERMIT FEE 5� 6v
I certify that I have read this application and state that the U1� V
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, 0
and hereby authorize re ntatives of this unty to enter TOTAL- FEE
u on t n roperty in. e n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date