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Home My Public Portal About9578 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS A P tl L C A II �ON I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY 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 BUILDINGLOCALITY ❑ ADDRESS Certified copy is filed with the county building inspection As NEAREST department OCALiTY OM P1 F e0 ` CROSS STxv Date Applicant LO EAREST DISTRICT "i'01 TYPE O SED BY CROSS ST C 1 CONST I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP ( 'GR NO, [7 (CIRCLE) STATE MAJOR SECOND LOCAL NO OF BLDGS. CL (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE 71AL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF 1 SIZE OF LOT EXISTING BLDG /�.� CcI certify that in the performance of the work for which this V � permit is issued, I shall not employ any person in any manner NER p_ so as to become subject to the Workers' Compensation Laws AiL OCCUPANCY GROUP �/ U r !/ ILI ADDRESS I]o Date Applicant TEL Cn NOTICE TO APPLICANT If, after making this Certificate of CITY NO. - &56oA. 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. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I her by affirm that I am licensed under provisions of Chapter SAFETY PERMIT'Q (LIST ITEMS BELOW) NO OF EXITS 9 (crmmencing with Section 7000) of Division 3 of the Busi- ness�nd Professions Code, and my license is in full force and PARKING . ((�� effect. SPACES REO'D I= PROVIDED License Number Lic Class LIMITED TIME USE 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- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPR P SENT USE OF BUILDING OVAL Lic.or Reg No. Date d 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- ness and Professions Code) NO PARKING SPACES PROVIDED ❑ 1, 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 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 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 .00 �L�L upo he bove mentioned pro erty for ins)ection purp ses SEE REVERSE FOR EXPLANATORY LANGUAGE U Vp 7i<g ati�L e owl Permittee Ifate �