The URL can be used to link to this page

Home My Public Portal About9028-9040 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION I hereby"aijrm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.). •� Policy No. Company FOR APPLICANT TO FILL IN BUILDINGADDRESS �A7 l�Zp Certified copy is hereby furnished BUILDING ,,� q� ?-SNS LOCALITY ADDRESS 0 Certified copy is filed with the county building inspection LOCALITY �� ! NEAREST department. CROSS ST Date Applicant NEAREST `( DISTRICT NO GROUP TYPE P ESSED BY CROSS ST. Rcg�► $lilt s�.O _� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G(J jj COMPENSATION INSURANCE DESCRIPTION I 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.) USE OF a slzE of Lor 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 owNERKetj `-D so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o ADDRESS ~' Date Applicant O. n L'I NOTICE TO APPLICANT: If, after making this Certificate of CITY J�J�I,tJ�OR Pi NOL �7�7,(d _4(033 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 El 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 ok-effect. PARKING REQ'D O PROVIDED D SPACES License Number Lic. Class S7 Q i 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 SIGN E mess and Professions Code). FINAL APPROVAL PRESENT USE OR BUILDING Lic.or Reg.No. Date W*L f HOME OWNER-BUILDER DECLARATION - NO. OF EXISTING BUILDINGS ON LOT AND USE Y� I hereby affirm that I am exempt from the Contractor's �I f_r!Ii I'i—`J={E E 1I: License Law for the following reason (Section 7031.5, Busi- ness usi _;5;.• ness and Professions Code) No PARKING 0 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). CONSTRUCTION LENDING AGENCY y— PROPOSED USE of BUILDING I hereby affirm that there is a construction lending agency fi4R"171,L(> ✓ 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 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 relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioged property for inspection purposes. L��yx�A / .1 SEE REVERSE FOR EXPLANATORY LANGUAGE , q Lt 'Signature of Permitteg V Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION 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 FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished UILDING i LOCALITY D A DRESS Certified copy is filed with the county building inspection NEAREST department _ LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. G OUP TYPE PROCESSED BY CROSS 3T. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 7 1 O } COMPENSATION INSURANCE DESCRIPTION LOT No. BLocK MAP ,��//�I HIGHWAY NOO(;/� (CIRCLE) STATE MAJOR SECONDLOC AL a (r' NO. OF BLDGS O (This section need not be completed if the work involved TRACT S NOW ON LOT USE ZONE SPECIAL CONDITIONS by-the permit is for one hundred dollars ($100) or less.) USE �,2 tY SIZE OF LOT EXISTING BLDG. O I certify that in the performance of the work for which this permit Is issued, I shall not employ'any person In any manner OWNER 0 I•bwiid I U so as to become•sublect to the Workers' Compensation Laws MAIL OCCUPANCY GROUP �Q�� W DDRESS w C. Date Applicant Z TEL OCCUPANT LOAD NOTICE TO APPLICANT If, after making this Certificate of CITY No. 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 GEOLOGY INSPECTION deemed revoked C] No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑ I hereby 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 REQ'D O PROVIDED D License Number Llc Class • 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 SIGNATURE iness and Professions Code). 4 FINAL APPROVAL �j RESENT USE OF BUILDING 4S5 ,Q� Llc or Reg.No" Date 11 1 , V HOME OWNER-BUILDER DECLARATION, NO OF EXISTING BUILDINGS ON LOT AND USE t I hereby affirm that I am exempt from the Contractor's 4 3 Q Q A License Law for the following reason (Section 7031.5, Busi- NO ness and Professions Code) SP PARKING SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the # 0 0.010 4-Q structure is not intended or offered for sale (Section o 0,0!0 oto o 7044, Business and Professions Code). PRoaosED USE of BUILDING • • ' (�fess 030'5-81 CONSTRUCTION LENDING AGENCY t—li ~ 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 Lend er'sAd dress 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 relating to building construction, TOTAL FEE hereby authorize representatives of this County to enter abov - ntioned propert r.inspection purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE- .Z po i Signature of ormittee Date