HomeMy Public PortalAbout10249 RANDWICK DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) � I�C�LLANEOUS APPLICATION S 11®
I hereby affirm that 1 have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insgre, or a cert�cate 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. wcc,D., OX , /` G gLOCALITY L47np1
0 Certified copy is filed with the county building inspection LOCALITYC�,f, NEAREST
department. �;IN� Lr ( CROSS ST.
Date Applicant NEAREST D TR ICT Nfff��� G����pppp LLLyyyPPFLLL TYPE s�J� PRO: SED&Y
CROSS ST. &LL C. �M (/ � ".L� CONST. // /7
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ° a �✓ l/VR-1��—
COMPENSATION INSURANCE DESCRIPTION I LOT NO. , BLOCK MAP HIGHWAY
NO. (CIRCLC) STATE MAJOR SECOND LOCAL
NO. OF BLD 65.
(This section need not be completed if the work involved TRACT i NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
I USE OF
SIZE OF LOT -� b , EXISTING BLDG. a
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNERK 44q uelzer ='
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
AD.RE-sr V
Date Applicant LLI
' ,m rQ C L TEL.(�p 6^� ^ OCCUPANT LOAD a
NOTICE TO APPLICANT: If after makingthis Certificate of CITY f No.
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 Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I`J
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. I ODi'1^ PARKIN
SPACESG REq'D D PROVIDED O
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 OFNO.OF / INSPECTO s
acting in, my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNAT E
iness and Professions Code). F FINAL APPROVAL lti
PRESENT USE OBUILDING I
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 _
I, as owner of the property, will do the work and the SPACES PROVIDED `-'
�'';
structure is not intended or offered for sale (Section A41Ts4
7044,Business and Professions Code). 3�ry 80.50
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ,I,�LI
I hereby affirm that there is a construction lending agency 1 ITEM'
for the performance of the work for which this permit is c
issued(Sec.3097,Civ.Q. TOTAL 4,3 5
. 0
Lender's Name CHECK 813.50
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE W).00
CHANGE .011
I certify that I have read this application state that the `)L00
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, 222/
and hereby authorize representatives of this County to enter TOTAL FEE 00013-00,01 11)=
upon the above-mentione property for inspection purposes.
/dam` ` SEE REVERSE FOR EXPLANATORY LANGUAGE '096' 1 ASI 9°43
Signa re of Permittee ate