HomeMy Public PortalAbout9626-9628 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
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 BUILDING
FOR APPLICANT TO FILL IN ADD RESS
❑ Certified copy is hereby furnished. BUILDING r ✓NAS LOCALITY (HI
Q ADDRESS 2 _ / S T>�P. i
Certified copy is filed with the county building inspection
NEAREST
department. LOCALITY C/7—Y CL}e.�F• CROSS ST.
Date Applicant NEAREST 7 ` 7 DISTRICTF.. GROU TYPE PROCESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO.S(, U BLOCK Mqp II�� s H,GRH qy }
rvD. •..[Q 6 (CIRCLE) STATE MAJOR SECOND LOCAL 4.
(This section need not be completed if the work involved NO. OF LOT USE ZONE SPECIAL CONDITIONS
P TRACT NOW ON LOT O
by the permit is for one hundred dollars ($100) or less.) U
USE OF
SIZE OF LOT EXISTING BLDG. ccI certify that in the performance of the work for which this �
permit is issued, I shall not employ any person in an manner OWNER I lee.
so as to become subject to the Workers' Compensation Laws. MAIL v D N ��Ln1A OCCUPANCY GROUP .2 w
ADDRESSq&2
Date Applicant 7L/� DQ a-
TZ
NOTICE TO APPLICANT: If, after making this Certificate of CITY L-i✓ c y NEoL. 2 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 No Spec. Knowl. ❑
deemed revoked. Panic DBViC@S ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. REO'D PROVIDED
SPACES
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
F-1
FROM: TO:
I am exempt from the licensing requirements as I am a.
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). r, ��7yQ� s� FINAL �0 ? .y�/
PRESENT USE OF BUILDING ry J Ci �'o`^^"��
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-
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). /7 /j� 21,10 5 � A
PROPOSED USE OF BUILDING FS/K�
CONSTRUCTION LENDING AGENCY V # • • • • 8 8
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is • • • • • • • z
issued(Sec. 3097,Civ.C.).
Lender's Name PROPOSED MAX. OCC. O q08-81
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,;7.5,OQ
and hereby authorize representatives of this County to enter
upon the above-mentioVed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
g x ture of Permitt Date