HomeMy Public PortalAbout9115 RANCHO REAL RD_Miscellaneous_1995-02-09 I r
WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
r
I hereby affirm that I have a certificate of consent tself CE 87501-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 1�ull
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
-A....
.DRE5
Certified copy is hereby furnished. BUDRESS
ILDING ,C �O LOCALITY
A
D .1 <J c•�C�
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CRDss ST.
Date Applicant NEAREST DISTRICT NO. G,$$$OUP TYPE CESSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. ICIRCLE) STATE MAJOR SECOND 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
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued,I shall not employ any person in any manner owN9R�L Tom- G ,� y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
�/ O� _ A t3
ADDRESS Z�Lo �
Date Applicant � a
NOTICE TO APPLICANT: If,after making this Certificate of CIT TEL.No. —���� OCCUPANT LOAD C/3
Exemption, you should become subject to the Workers' APPLI TION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with comply with such provisions oI this permit .shall be TRAILER USEGEOLOGY INSPECTION E]deemed revoked. ❑ 13 No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 5J-- Panic Devices El
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 REQ'D D PROVIDED
SPACES
License Number Lic. Class G% �L LIM9TED TIME USE
Contractor Date DATE! DATE
PROMI TOI
El I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE o NO. OF, INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SydyATURE
iness and Professions Code). FINAL APPROVAL /
PRESENT USE OF BUILDING Z• //1
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 n'•-�' •a
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING '130
+ M
I, as owner of the property, will do the work and the SPACES PROVIDED f I�`�IE
structure is not intended or offered for sale (Section
7044,Business and Professions Code). .1!j( � -= m =°5
CONSTRUCTION LENDING AGENCY PRoroseD USE of BUILDING '( " =� ¢
1_f!t_f: irL c_•_
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.Q.
Lender's Name _ _
PROPOSED MAX. OCC. --' ' ' y .
Lender's Address !.:! !:!:—!.:! !�3. � •:f`: _
I certify that I have read this application and state that the PERMIT FEE go 90213 i AM I i:US
p'
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances
and State las relating to building construction,
and herebyauthorize representatives of this County to enter TOTAL FEE 6
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig�atur. f Permittee ate