HomeMy Public PortalAbout9056 RANCHO REAL RD_Miscellaneous_1991-01-30 WQRIGERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. ADDRESS 150ISC; EZ iCA C, ?.F_ A4- LOCALITY �1_ �-
ElCertified copy is filed with the county building inspection LOCALITY - NEAREST
department. T j✓M (-e—_ CI cC„ CROSS ST. �it�ic ov
Date Applicant NEAREST / -T .gg Q /�L� J �7 DISTRICT NO GROUP TYPE P CESSED BY
CROSS ST. •c.,utAmi 4L F�Af-leto 17-Ccl�r. �O (� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d ^�
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLD GS.
(This section need not be completed if the work involved ITRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
0�..
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 111 C,
permit is issued, I shall not employ any person in any manner OWNER L -4 111` Ing LT y
so as to become subject to the Workers' Compensation Laws. MAIL
Date Applicant w,��// OCCUPANCY GROUP Yi]
0
ADDRESS �Q sG $C.�''�, eAL6 1P l_ r_ V
TEL. a-
NOTICE TO APPLICANT: If,after making this Certificate of CITY �h'i 4� �; No. to-7.&C-00.3 OCCUPANT LOAD
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
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 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 I NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. Tp 1�tS �C� L-I., �)/.15't PARKING
SPACES REG'D r.� PROVIDED
License Number Lie. Class o Cp C T.�+e�'t Lv rpt �J J
LIMITED TIME USE
Contractor Date 4t j I C (,�7 i IlNov1ZP r C
DATE DATE
I am exempt from the licensing requirements as I am a FROM: TOI
licensed architect or a registered professional engineer SIZE OF NO.OF iN
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG CTORGNATUREE
iness and Professions Code). FINAL APPROVAL JAV-71 1
Lic.or Reg.NDate PRESENT USE OF BUILDING
o.
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's I_I
License Law for the following reason (Section 7031.5, Busi-
ness
' '
and Professions Code): No. PARKING v,';fl+ '?,o l
ElI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section I �'
7044,Business and Professions Code). TOTAL 93 e 01.3
PROPOSED USE OF BUILDING PA,-ria COKE�I..S
CONSTRUCTION LENDING AGENCY CHECK. 93.00
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is GE•j(NGEE .00
i
issued(Sec.3097,Civ.Q.
Lender's Name
Lender's Address h 1
PERMIT FEE PROPOSED MAX. OCC. 13001 l-010131 �.s-6L'•/I;
I certify that I have read this application and state that the t1 J 5 37I i Ftp'! •`_,:'31,
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 3
upo a above-mentioned propert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
)o
L
Signature of Permittee Date