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Home My Public Portal About8837 1/2 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATIONDECLARATiON CE 875 (2-80) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have certificate of consent to elf 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.) BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADUREss ❑ Certified copy is hereby furnished. C, BUILDING LOCALITY RDOR ❑ Certified copy is filed with the county building inspection LOCALITY -�` NEAREST: department 1`—Jtn_ CROSS ST. Date Applicant EAREST DISTRICT NO. GROVP IT PE PPO ESSED BV CROSS ST. Lj Q Co..,. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK mNwA. } NNO.. (CIReLE) STATE MAJOR SECOND LOCAL 0. O. OF BLDGs. (This section need not be completed if the work involved TRACT NOW ON LOT VSE'•ZONE SPECIAL CONDITIONS Q by the permit is for one hundred dollars ($100) or less.) USE OF 1 certify that in the performance of the work for which this SIZE OF Lor EXISTING BLOB. 6130 permit is issued, I shall,not employ any person in any manner I 1=Ci L_ Ar J�,7ss so as to become subject to the Workers' Compensation Laws. AILpOCCUPANCY GROUP W to ADDRESS t' 14. Date � Applicant -a- ''vaX. 1 SE� NOTICE TO APPLICANT: If, after making this Certificate of CJTr ��lPC� (..v I L. rvo. 'A 2,5 —C i45 OCCUPANT LOAD — Exemption, you should become subject to the Workers' - Compensation provisions of the Labor Cade, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER VSE GEOLOGY INSPECTION El No Spec. Knowl. deemed revoked. El . LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that 1 am licensed under provisions of Chapter SAFETY,PERMIT q (LIST ITEMS BELOW) 9 '(commencing with Section 7000) of Division 3 of the Buse rvo. of EXITS riess_1nd Professions Code, and my license is in full force and PARKING etYtCt SPACES REO'O D PROVIDED D Lice fie,Number - Lic. Class LIMITED TIME USE Contractor Date DATE o.re 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. sro Rl Es SIGNATURE iness and Professions Code). f'J . RESENT USE OF BUILDING \/fA� FINAL APPROVAL �t Lic.or Reg.No. Date— HOME ate HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that l am exempt from the Contractor's - License Law for the following reason (Section 7031.5. Busi- No' PAR :24638A ness and Professions Code): PRO SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the # e e e a 88 structure is not intended or offered for sale (Section 7044, Business and Professions Code). RoroseD USE of amLDING e;ole, z CONSTRUCTION LENDING AGENCYQ uS 08 1 9—8 3 I hereby affirm that there is a construction lending agency :a- pe c�iDAl pa� for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). -t•e53 Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the ISSUANCE FEE above information is correct. 1 agree to comply with all County ordinances and State laws relating to building construction, TOTAL FEE !•' QO and hereby authorise representatives of this County to enter u on the above-mentipped prope y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date - WORKERS'COMPENSATION DECLARATION 7 CE 85 (2-80) MISCELLANEOUS APPLICATION - qq CE 875 C - I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES. BUILDING AND SAFETY DIVISION insure, or a•certificate of Workers' Ins Compensation Insurance,or a certified copy thereof(Sec.3800, Lab.C:) - Policy No. Company FOR APPLICANT TO FILL IN BUILDING AODRESS ❑ Certified copy is hereby furnished. mLDIrvG DORESLOCwLITY Certified copy is filed with the county building inspectionWREST mLOCALITY ' departent. .� ROSS ST. Dat2 Applicant + NEARESTDISTRICT NO. f GROUP TY E PRO SSEO BY 'CROSS ST. .41 CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL h COMPENSATION INSURANCE DESCRIPTION LOT No- BLOCK ,GM WA No.. (C,Pc LE) STATE MAJOR SECOND LOCAL a . (This $eCllOn need not be completed if the work involved OF LOGS. VOIVed TRACTNOW. ONSLOT USE ZONE SPECIAL CONDITIONS o by_ the permit is for one hundred dollars ($100). or less.) USE oP - U SIZE OF LOT EXISTING BLDG. W I certify that in the performance of the work for which this - - 0 permit is issued, I shall not employ any person in any manner WNE, F- 14 so as to_become subject to-the Workers'Compensation Laws. wDR J OCCUPANCY GROUP f /� IU RE55 d 1 It 0,I$ III ///••[[[ �� Il Date Applicant W NOTICE TO APPLICANT: If, after making this Certificate of rY No� .00CUPANT LOAD z Exemption, you should becomesubject 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 VSEGEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl.• El LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑. Ithereby affirm that I 'am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS 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. effect. SPACES ' REO'. D PROVIOEO D License Number Lic. Class LIMITED TIME USE Contractor Date' DATI DATE _ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE oPwruRE - INSPECTOR'S acting in my professional capacity (Section 7051, Bus- Exlsn rvG BLDG. ND.RIFs sw N iness and Professions Code). No:of FINAL APPROVAL RESENT USE OF BUILDING ,LiL or Reg.No. Date - V HOME OWNER�BUILDER DECLARATION NO. of Ex ISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the -Contractor's _ p [[ /j License Law for the following reason (Section 7031.5, Busi- NO. PARKING 2 5 8:5 G A ness and Professions Code): ` SPACES PROVIDED I, as owner of the property, will do the work and the '#le e e�e Q Q structure is not intended .or offered for sale (Section 7044, Business and Professions Code). ete,e eJe,e s e N RPE OOSO USE OF BUILDING 'Za CONSTRUCTION LENDING AGENCY 1 0•a 2.b)—a I hereby affirm that there is a construction lending agency ( t - for the' performance of the work for Which this permit'is - issued (See. 3097,Civ.C.). I' Lender's Name PROPOSED MAX. OCC. ' Lender's Address PERMIT FEE 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)J relating to building construction, TOTAL FEE and hereby au thD a ep'/esenI Ives of this County to enter - - po e u Ove- d erty for inspection•purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gig '' u rm ttee Date I tWOK MFRS'COMPENSATION DECLARATION 76M444 CE 875 (11-84) MISCELLANEOUS APPLICATION ppLICATIOA y n affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IL JI insure, or a certificate of Workers'Compensation Insurance,or a ceitifiel copy thereof(Sec. 3800,Lab.Q. o �/ Policy No. Company FOR APP LICANT TO F I LL I N ADDRESS Certified copy is hereby furnished. BUILD ING� 03 N� Lo cw ury E ❑ Certified Copy 1S filed with the county building inspection ADDR SS LOCALITY NEARESTI eel depaxtment.. CROSS 51. Date Applicant NEAREST OIS TRICT N G�JUP TYPE / ESSEO BY CROSS ST. IO� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL .•FFYY 0` Y COMPENSATION INSURANCE DESCRIPTIOry LOT No. BLOCKHIGHWAY STATE MAJOR SECOND LOCAL NO. OF SLOGS. (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 _ EXSTIING BL G. d I certify that in the performance of the work for which this permit is issued, I shall not employ any person To any marmer O W NE - ® v so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP I=_ fA`l. MDDRESS AIL CD A / U DateZ Applies i ' � � ��• U L � w ( N NOTICE TO APPLICANT: after making this Certificate of clrr �' (�" NO. OCCUPANT LOAD - —0 lf•� Exemption, you should become ame subject to the WorkersAPPLICATI NFOR EXIT HARDWARE. z 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. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 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 7 effect. /Jl�.�i PARKING SPACES REO,. PROVIDED License Number Lic. Class �' Q�V 1 LIMITED TIME USE Contractor Date DATP DATE I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF No. OF INSPECTOR'S licensed acting in my professional capacity (Section 7051, Bus- EXISTING w STING BLDG' sroRlEs sIGNArORE iness and Professions Code). R ^ p P ESENT USE OF BUILDING g L L FINAL APPROVAL / i Lic.or Reg.No. Date L HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors f ? 11[i�t'_ '�' 0 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKINeEl L;+j,i,a J• I, as owner of the property, wig do the work and the SPACES PROVIDED , structure is not intended or offered for sale (Section 7044,Business and Professions Code). USE of CONSTRUCTION LENDING AGENCY a OPOsen 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is a issued(Sec. 3097.Civ.Q. Lenders Name PROPOSED MAX. OCC. Lender's Address 1 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 he authorize representatives of this County to enter TOTAL FEE d' , n theaov,-mentic n,eF,, roper) for inspection purposes. [ -3 1.2-11411 � `/i{— SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Earl/ 4t