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Home My Public Portal About8905 LAS TUNAS DR_Miscellaneous__ J , ��rr cfORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION Insure, o affirm that I have a -certificate of consent nc 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 FILL IN BUILDING ❑ Certified copy is hereby furnished. BUILDING C ' LOCALITY ❑ .7 Certified copy is filed with the county building inspection DDRESS / NEAREST department. LOCALITY /1. CROSS ST. Date Applicant NEAREST ` 1 DISTRICT NOJJyJ� G U TYPE PROCESSED BY CROSS ST. O /y CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL P COMPENSATION INSURANCE DESCRIPTIO {©ON LO O. 0- BLOCK MAP � /n HIGHWA; } NO. p� }U (CIRCLE) STATE MAJOR SECOND LOCAL a NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT �� USE ZONE SPECIAL CONDITIONS O' by the permit is for one hundred dollars ($100) or less.) USE OF I certifythat in the SIZE OF L EXISTING BLD G� performance of the work for which this Q permit is issued, I shall not employ any person in any manner WNER H so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W ADDRESS ve iL Date Applicantel / to NOTICE TO APPLICANT: If, after making this Certificate of IrY • oL 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 USE 0 GEOLOGY INSPECTION NO Spec. Knowl. ❑ deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (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 ==7P..111...V REO'D PROIDED D License Number Lic.Class LIMITED TIME USE Contractor Date DATE O ATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF 1NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). RESENT 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 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING -2'4'616 3 A SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure isnot intended or offered for sale (Section S �,� , # D D 00 4 0 7044, Business and Professions Code). • ' PROPOSED USE OF BUILDIN 0 0 0 0 0 0 0 } CONSTRUCTION LENDING AGENCY ` 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 PERIYIIT 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 relating to building construction, TOTAL FEE and hereby auth rioze repre entatives of this County to enter upo the abov me erty:for inspecti p ses. SEE REVER FOR EXPLANATORY LANGUAGE Signature of Permitte Date