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Home My Public Portal About9441 1/2 - 9445 1/2 LAS TUNAS DR_Miscellaneous_11/28/1988_Three Amigos WORKERS"COMPENSATION DECLARATION CE 875 (11-84) M I SC E L LA N EO U S APPLICATION CE 875 I hereby aff>rri that I have a 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 Np. Company FOR APPLICANT TO FILL IN BUILDING 2, Certified copy is hereby furnished. BILDINGULOCALITY ADDRESS C/�V 0 Certified copy is filed with the county building inspection LOCALITY NEAREST. department. CRbsS sT. Lam_ Date ApplicantNEAREST /� / DISTRICT N . T E PRO S ED BY NACROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP H..-AY NO. (CIRCLE) STATE MAJOR SEC ND OCAL - NO.-OF BLDGS. - (This section need not be completed if the work involved TRACT NOW ON LOT US�j NE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF / I certify that in the performance of the work for which this sl,zE of Lor EXISTING BLDG. CD 0 permit is issued, I shall not employ any person in any manner OWNER rp FBLDG Q =' so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP,-, - o ADMAIL i- " ��. �,. © •' _, .J Date DRESS Applicant UJ NOTICE TO APPLICANT: If, after making this Certificate of cITY (J V G NE., — OCCUPANT LOAD z Exemption; you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ ❑ ❑ No Spec. Knowl. deemed revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. ®iV L//7/�1�� PARKING REQ�D PROVIDED _ SPACES License Number Lic. Class �`�` / �Z�/� �� _ .�� 3 LIMITED TIME USE Contractor Date DATE DATE FROM: TO: El I am exempt from the licensing requirements as I am a' licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING �� Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED •1 .2 Q4 R t structure is not intended or offered for sale (Section 7044,Business and Professions Code). ® o;© 8$In CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING r Vl /� 4 •1,2 8"t8 8 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. Lender's Address ' L certify that I have read this application and state that the PERMIT FEE 2 5 lo above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, d hereby authorize representatives of this County to enter TOTAL FEE on the above-mentioned property for inspection purposes. ��—_ �„ �� • SEE REVERSE FOR EXPLANATORY LANGUAGE S' ure of Permittee•`�' Date