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Home My Public Portal About9167 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION MISCELLANEOUS APPLICATION J� 875 � CE CE 875 (11-84) 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 certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING / C'�vE LOCALITY ADDRESS "/ a�k FICertified copy is filed with the county building inspectiony LOCALITY NEAREST department. CROSS ST. - Date Applicant NEAREST �� DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. 6—, J/.-• CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGH AV NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLD65. (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. 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 OWNER OCCUPANCY so as to become subject to the Workers' Compensation Laws. GROUP C�t MAIL O ADDRESS F--• Date Applicant L NOTICE TO APPLICANT: If, after making this Certificate of CITY TNO. OCCUPANT LOAD 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices a 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 REp'D O PROVIDED D SPACES License Number Lic. Class /'LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as'l am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SP NATURE iness and Professions Code). PRESENT USE OF BUILDING �� FINAL APPROVAL 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 AIN`'T.rr License Law for the following reason (Section 7031.5, Busi- NO FEE ness and Professions Code): NO. PARKING DI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section '�`- - -j 7044,Business and Professions Code). -2) ;' CONSTRUCTION LENDING AGENCY -PROPOSED USE OF BUILDING lc'14" ' 1 AM 05 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.). �\0 ` Lender's Name f�) PROPOSED MAX. OCC. Lender's Address PERMIT FEE s Q I certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, hereby authorize representatives of this County to enter TOTAL FEE n the above- ntioned pro ert or ins c ion pu ose SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Ate WORKERS'COMPENSATION DECLARATION CE 8454(11.84) ---MISCELLANEOUS APPLICATION I heeaffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,, o or a certificate of Workers'Compensation Insurance,or a certified copy thereo (gSec. 3800 ab.C.). -y� Policy No. I 2- ompanyp`-�ws, C-%M FOR APPLICANT TO FILL IN BADDRESS 7 1 Certified copy is hereby furnished. UILDING AD RESS LOCALITY 0 Certified copy is filed with the county building inspection f, LoCAL.TY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT N GROUP CTYPE P OCESSED BY CROSS ST. ��*� �J ONST , CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' ✓1 f COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP ....WAY _ 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.) USE OF T.* - SIZE OF LOT EXISTING BLDG. / d I certify that in the" erformance of the work for which this 0 permit is issued, I shall not employ any person in any manner OWNERTs� so as to become'subject to the Workers'"Compensation Laws. MAIL (//JL/�] �7� �-FOC66PANCY. GROUP o ' ADDRESS [L(/�`, /�G --.�� Date Applicant rEL. Lu NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. �� OCCUPANT LOAD N 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 or this permit shall be TRAILER USE ❑ GEOLOGY 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 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 O PROVIDED D SPACES License Number Lie. Class j"/ /G' LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE iness and Professions Code). - PRESENT USE OF BUILDING FINAL APPROVAL v-( Lie.or Reg.No. Date Z ' O � HOME OWNER-BUILDER DECLARATION NO, of EXISTING BUILDINGS • ON LOT AND USE 0 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 7044,Business and Professions Code). .� r CONSTRUCTION LENDING AGENCY PROPOSED USE: of BUILDING 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.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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORK LRS' '_liMl'LNSAfIUNDE( L %Rulcl. ; ;I,;;.:I11",, , :Il, MIS(.LLLANLCaUS AI-'t'L1(:A1'1UN I hereby ai'tlrnl that I have tl ccitilicatc of coit,cnl III sell COLINIl' Of LOS ANGEL FS BUILDING AND SAFETY DIVISION I insure,or a Certllicate of Workers'Conlpciismion In,ul,lnLe. Ill .I certified copy thereof (Sec. 3800. Lab. C) Policy No Company FOR APPLICANI TO FILL IN BUILDING BUILDING S //q ADDRESS ElCertlf Ted copy Is hcieh\ luini,licd / �y SA \ --- LOCALITY ❑ Ceryl led copy Is I Iled wuh the county bulldnlL m,peLuOn Cl !!!��QF� {{�{� ZIP / — department ITX / (IIIJJJJ��,,,,JJJJ NEAREST CROSS ST Date.- __ Appllcalll SIZE bF LOT NO OF BLDGS.NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CONST 1 CLRlll ICAIL'OF LXLMPI ION FROM 1VORK1 RS' TRACT BLOCK LOT NO COMPLNSAI ION INSURAN(L AlMHIGHWAY ✓ I I I NO ICIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the \cock in\ol\Cd ASSESSOR MAP BOOK PAGE PARCEL 115E ZONE SPECIAL CONDITIONS r" by the permit i% for one hundred dollars (,+1001 or Ic%%.) I CL'ltlly that Ill the pCll'0IIo ILC til IIIc Nuck [III wb,Lll Illi, OWNER TEL NO. ( i _ -- L- permit is Issued. I shall not employ any peiu)n u1 ,uly n1,uulCl t t 1 . so as to become Subject to the WOikersConlpen,atio.1 L,I\\, ADDRESS OCCUPANCY GROUP l t" Date--— _ Applicant CITY ZIP t z." NOTICE TO APPLICANT. 11' aftCl nldkrllg Ihrs (eltifna(e OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation pro\Isions of the Labor Code you must 101-thwlth Comply with such provisions lir this perllllt slmll be ,lC'ellIC(l TRAILER USE❑ GEOLOGY INSPECT ION❑ No Spec Knowl ❑ revoked. OCCUPANCY INSPECTION Panic Devices ❑ LICENSED CONTRACTORS I)!ATARAIR)N hereby affirm that I am licensed Linder provisions of I, hal)ter SAFETY PERMIT IJ (LIST ITEMS BELOW i I 9(commencing with Section 7000)of DI\Islon 3111 the BLIs111eSs – _ NO OF EXITS and Professions Code,and niy license is nl lull force and effect License Number I-Ic Class � /, � - PARKING REO'D PROVIDED 1 SPACES C011tiact0l D.IIL' ' I I �� LIMITED TIME USE DATE DATE v ❑ I and exempt from the licensing requitements I, I Gill it FROM TO licensed architect or a registered piofc„mnal engineer ' acting in niy proIcssioRal capacity (Scction 7051 thlslncss SIZE OF NO OF INSPECTOR'S 7 EXIS rING BLDG bl URI[S SIGNATURE and Professions Coder -- ___[NI) --- _---- LIC. or Reg No Date PRESENT USE OF BUILDING FINALE APPROVAL07 I IIOML OWNI-R-111)[1 DI-K DI ( LARAIION NO or I XI5l ING BUILDINGS ON LOT AND USE / hereby affuin that 1 .1111 C\Cnlp( 110111 the ( 011HAL101', I ILCINC -- ----- — Law for the following Ie,ISOn (Section 7011 >. Business ,Ind Professions (ode) NO PARKING SPACES PROVIDED as ownci o[ the piopcity \\Ill IIII IhC N,nk ,111d Ilse --------- — -- --- --- -- -- — ' MI 11L'IIIIC I, TIO( Intended 111 uIIeICLI lul SAC (SCCI I III I0-44. PROPOSED USE OF BUILDING BuSlness and Plofesslons Code) rry CONSTRUCTION 1.1-NI)IN(i Md N( Y hereby a111rn1 Thal thele I, ,I L•011stt ICuOn ICIILIIIIL .ICeIII-\ I'll the performance of the NOIk for \\hlch Ihls pelnlit i, Issued — -- — -- ---- (Sec. 3097, Civ C.) PROPOSED MAX OCC Lender's Name A1141CANT IPHI,' c - Z4 y CAinVf Ff►L�qRV� Lender's Addies, ADD I certify that I have lead this application and ,i,itc Jim the qlz o •' �� above information Is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building cons[riellon.and hereby authonie replesentati\es of this (ounty t0 enlcr upon ISSUANCE FEE the above-mentioned properly fol in,peLtion pulpu,c, �) I TOTAL FEE J D o Y SEC REVERSE EOR EX131_ANATORY LANGUAGE Signature of Permittee D.•le I