HomeMy Public PortalAbout9612-9614 LAS TUNAS DR_Miscellaneous__ `VORKEAS'COMPENSAFION DEC'LARAFION A,M'114 MISCELLANEOUS APPLICATION
20-0063DPW 1 Y i 9U
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION l�
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 //)
X BUI DING ADDRESS ADDRESS (G !X
El -Certified copy is hereby furnished. U" s o o w S br I Ve LOCALITY
❑ Certified copy is filed with the county building inspection CITY i ZIP/� -7 NEAREST
C tN
department. 1 L' 1 "1" _1 18 0 CROSS ST.
Date ,4ppllCant _- - SIZE OF L T NO.OF BLDGS.NOW ON LOT DIST I T Nps G P TYPE � OCESSED BY
G(O//r CONSTv
CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NG.
COMPENSATION INSURANCE HIGHWAY
10. (CIRCLE, STATE MAJOR SECOND LOCAL
(This section need not be completed if the Nork in%olved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
b)' the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this- OWNER i� 1 Q - � EL NO. _G� Sv
permit is issued. I shall not employ any person in any manic Property ISe Y OWY1 �IS 2.� ! 3�'
so as to become subject to the Workers' Compensation Laws ADDR!<g5
main OCCUPANCY GROUP
Date ApplicantCITY ZIP
NOTICE TO APPLICANT: 11, after making this Certificate}; I OCCUPANT LOAD
of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code.you must forthwith _
comply with such provisions or this permit shall be deemed TRAILER USE L-' GEOLOGY INSPECTION L I No Spec.Knowl. ❑
revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT O ILIST ITEMS BELOW,
9(commencing with Section 7000)of Din inion 3 of the Business NO.OF EXITS
and Professions Code.and my license is in full force and effect.
a 412 PARKING REO'D [== PROVIDED
License Number _ ._ _ Lic. Class - SPACES
Contractor ______ _ _. —_ Date _ LIMITED TIME USE
DATE DATE
❑ 1 am exempt from the licensing requirements as I am it FROM: TO:
licensed architect or a registered professiomll engineer - —F INSP CTOR'S
acting in m) professional Capacit) (Section 7051. Business SIZE OF \C OF ATURE
and Proiessions Code). EXISTING BLDG -_ SrGR1E5
Lic. or Reg. No. Date PRESENT USE OF BUI,DING FINAL APPROVAL ko
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINCS V
ON LOT AND USE
hereby affirm that I ant exempt from the Contractor's License
Law for the following reason (Section 7031.5. Business and
Professions Code): NO.PARKING
E] 1. as owner of the properq. will do the wSPACES PROVIDED work and rhes,
�t�1 Sof
structure is not intended or offered for sale(Section 7()44. 1 PROPOSED USE OF BUILDING j
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fur
the performance of the work for which this permit is issued
(Sec. 3097.Civ. C.). PROPOSED MAX.OCC
Lenders Name ___.-_-_ ._-. APPLICANT(PP/f17; TEL NO,
Lender's Address — _-- ADDRESS
I certify that 1 have read this application and state that the
above information is correct. I agree to compl)'with all County PERMIT FEE
It ordinances and State laws relating to building construction,ant I
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes.
. X / w S TOTAL FEE
_ SEE REVERSE FOR EXPLANATORILANGUAGE
LAjignature m Datc