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Home My Public Portal About9150 LA ROSA DR_Miscellaneous__ WORKERS-COMP S TION DECLARATION •76M444 J -y CE 875 (2-80) MI'SC:ELLANEO�US, ASPPLICATION - I her y affirm that I h v tificate•.of consent to self COUNTY OF LOS ANGELES BUILDING•AND-SAFETY:DIVISION ,Insure, or a certificu I . kers'Compensatiori Insurance,or - a`certified copy thereof(Sec. 3800,Lab..C) Policy•No. ,Cbmpan.y" FOR'APPLICANT TO FILL IN' BUILDING + CC ADDRESS -Certified copy is hereby furnished. ulLgiNG LOCALITY , f ADDRESS, - - - ,❑ Certified copy is filed-with the county building inspection 1 NEAResT, r d'epartnient, OCALITY 4 CROS ST •Date Applicant 4. EAREST - `DISTRICT'NO - G OUP. TYPE .- PRO SSED BY • - CROSS ST_ ` S� CONST CERTIFICATE OF EXEMPTION-FROM WORKERS'-, LEGAL " DESCRIPTION LOT NO. BLOCK MAP - +.HIGHWAY +' COMPENSATION INSURANCE' +.''` ' STATE•MAJOR SE OND LOCAL • h - ' ' ' NO. OF BLDGe. . F .. ,(CIRCLE). - O (This section'need be.complefed if-the work Involved' TRACT• NO,W,ON LOT USE ZONE",SPECIAL CONDITIONS V by the -permit,is for one hundred,,dollars:,($100) ,or•less.)'. - USE'OF IZE OF,LOT. - EXISTING BLDG:_ I t �I� certify that in:the performance of the_work'for'which this O�permit is issued, I shall not employ-ariy person in,any;manner' . ,OwNE so as,, become.subject io'the Worker's' Compensation Laws. _ OCCUPANCY GROUP W - AlL •� - , _ _ i' ADDRESS Dafe APplican-t. N NOTICE TO APPLICANT: If, after making this-Certificate.of clrr rio� .•: OCCUPANT LOAD z '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[jGEOLOGY INSPECTION NO Spec: Knowl:" ❑ deemed revoked. Panic Devices' ;❑ 'LICENSED CONTRACTORS DECLARATION, --OCCUPANCY INSPECTiONIE] I hereby-affirm'that'] ariy-licensed under provisions of-Chapter SAFETY PERMIT'.q -(LIST-ITEM_S 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 SPACES . effect. REO'D O PROVIDED �. - -- - License Number Lia. Class LIMITED-'TIME USE . Contractor - "Date` r DANE DATE FROM TO: ' I,arn,"exempt,,from the'licensing-requiienients as I am a1. licensed.architect or,a ,registered professional engineer slzE OF >r NO. OF INSPECTOR'S - acting'in my professional capacity,„(Section 7051, Bus- XISTING BLDG;. STORIES SIGN ATU E. t mess and Professions`Code). _ PRESENT USE OF BUILDING' FINAL APPROVAL _,ff/ Lic.or Regal obi Date , HOMEOWNER-BUILDER DECLARATION NO.of Ex'isrlN� BUILDINGS -, - - ON LOT AND USE - I hereby.,'affirm that, I am 'exempt from the ,Contractor's' v License Law for the following reason'(Section 7031'.5, Busi- ness and"Professions Code): i NO.PARKING " ' SPACES PROVIDED.. I, 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): - . fIJ N r- PROPOSED,U SEOF BUILDING' CONSTRUCTION-LENDING AGENCY �',7 8.9,4•A' ,'I hereby -affirmrthat-there is'a construction lending agency for ane performance of'the',work .for. wjiich this permit,is __TjbL I, ' �,'� #"o i� • Issued(Sec. 3097,Civ.C.). Lender's Name - PROPOSED•MAX. OCC. •'i0 • e •,•• s z =Lender's Address_ PERMIT FEE •`,• •O.9,1 -.87 I certify':that I have mead this applicatibri-and-state that the above information is correct. I agree to:•comply with all County . !ssuANce FEE ordinances and State laws relating to.building construction, ' n and-her'eby'authorize representatives-of this County to enter TOTAL FEE u ri'the.above-mentioned roperty for inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE A " ignature of Permitt a Date— WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby-affirm 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+eertified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING IL ADDR SSS p/�b 1 A �aS/� LOCALITY 7 FCertified copy is filed with the county building inspection LOCALITY / -� NEAREST department. CROSS ST. Date Applicant NEARESTfL� '� DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. L/NC�� I H CONST. - CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY • N0. (CIRCLE) STATE MAJOR SECOND LOCAL ' NO. OF BLDGB. ' (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 SIZE OF LOT EXISTING BLDG. 1 d I certify that in the performance of the work for which this ,1 o permit is issued, I shall not employ any person in any manner OWNER ��Yo to m Crzi.ov so as to become subject to the Workers' Compensation Laws. MAIL OCCUP.ANCY4 GROUP' o Date Applicant ADDRESS 6TEL 'NO. OCCUPANT LOAD ( x NOTICE TO APPLICANT: If, after making this Certificate of CITY Cr•%Irl p /4• No. 3 3 �✓� ��(,� N d Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION ❑ Panic Devices LICENSED CONTRACTORS DECLARATION 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. S I►1 C T 1 / k s PARKING SPACES REQ'D D PROVIDED D License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. CF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS yy77 ON LOT AND USE L'8 1 2 7 A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- # 0-0 0,030 ness and Professions Code): NO. PARKING SPACES PROVIDED 1 I • • 8 Q 5,0 I, as owner of the property, will do the work and the •, '� , ,` .� � � � . structure is not intended or offered for sale (Section Z ` e' o>o _ 7044,Business and Professions Code). _ 8 PROPOSED USE OF BUILDING - I -i-_� -, L,I al 55 $•7 CONSTRUCTION LENDING AGENCY ' y 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.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE above Information is correct.1 agree to comply with all County ISSUANCE FEE �. ordinance nd State laws relating to building construction, and he y autho ' representatives of this County to enter TOTAL FEE upon Ie ove- entio ed o y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature d Permit Plarte WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I 1 hereby affirm 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 f,I a certified copy thereof(Sec. 3800,Lab.C.). 42 42 - �� Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. X Bu1LDING 5 D /A ZS ADDRESS LOCALITY j ) Certified copy is filed with the county building inspection LOCALITY if NEAREST Temple Cit department. P Y CROSS ST. Date Applicant NEAREST DISTRICT NO GR P TYPE OCESSED BY CROSS ST: /S'+N II 7 �j:O�i CONST. I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v UA COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) - 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.) USEOF ISTING BLDG. I I certify that in the performance of the work for which this SIZE OF LOT EX JL lipc JL 1-Y permit is issued, I shall not employ any person in any manner OWNER- O TM so as to become subject to the Workers' Compensation Laws. MAIL � OCCUPANCY GROUP ADDRESS�,OI �1:1:7YzZ �6+AMTZA CTT ' i j Date Applicant TEL• 4pa(p OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 335— 2f 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 F deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION S% Panic Devices I hereby affirm that I am licensed under provisions of Chapter - SAFETY PERMIT ❑ (LIST ITEMS BELOW) �j 9 (commencing with Section 7000) of Division 3 of the Busi- n NO. OF EXITS ness and'Professions Code, and my license is in full force and effect. SPACESARKING REQ'D PROVIDED I License Number Lic. Class �� LIMITED TIME USE Contractor Date DATE DATE D I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF No. OF INSPECTOR'S acting m 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 q I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS D y I s ON LOT AND USE I hereby affirm that I am exempt from the Contractor's Y7V/ �j License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, will do the-work and the SPACES PROVIDED structure is not intended or offered for We (Section �J 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING I hereby affirm that-there Is a construction lending agency �� f ��G `t 7-70 Al for the performance of the work for which this permit is ti issued(Sec. 3097,Civ.C.). .i Lender's Name PROPOSED MAX OCC 1�1 Lender's Address I certify that I have read this application and state that the PERMIT FEE 25.00 above inforInation is correct.I agree ply with all County ISSUANCE FEE ! ordinance and State ws P' es ilding construction, �— and here au rize a eshis County to enter• TOTAL. FEE 2r,�00upon the bov -ment' ed pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ` 1 f Permittee Date