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Home My Public Portal About9075 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76CE 8454(11-64) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, ora certificate of Workers'Com ensation In'surr/�_a-/nncc�ee,,,or a certifie�� La 7 J /'-� ' BUILDING D6Policy N pan FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. u1LDINc J QV �, LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection ALITY 'T / NEAREST department / CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUPTYPE ItESSED BY CROSS ST ��",,.F -� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 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 I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG o permit is issued, I shall not employ any person in any manner OWNER sr so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP IIG{ I o ADDRESS �' � Date Applicant 1„ T O. NOTICE TO APPLICANT If, after making this Certificate of CITY TE '21776OCCUPANT 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 D PROVIDED M �Q/�S l e SPACES License Number Lic. 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGrjykTURE mess and Professions Code). FINAL APPROVAL PRE NT USE OF BUILDING �•2 � 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 ❑ I, as owner of the property, will do the work and the SPACES PROVIDED y structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED use OF B ILDING I hereby affirm that there is a construction lending agency 4 a o,6 1-e aw eat a, 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 CJ� 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 rbpresentatives of this County to enter TOTAL. FEE upon t bove-m ntionedMa nspection pu oses —.11JAZZ7/10y, � !�]-�� Lj SEE REVERSE FOR EXPLANATORY LANGUAGE 14ULI-A,4 111 S&hature of Permittee Date ��JJ WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS A P P L ICAT 10 N insure, hereby affirm that I have certificate of consent- self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION sure, or a certificate of Workers' rs'Compensation Insurance, e,or a certified copy thereof(Sec.3800, Lab C) BUILDING `�((((AIA �A Policy No Company FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy'is hereby furnished BUILDING LOCALITY �" ADDRESS 9075 East Las Tunas Drive Tempi-F. ❑• Certified copy,Is filed with the county building inspection NEAREST department LOCALITY Tem Ze City CROSS ST StLI�uKa— DateApplicant AREST DISTRICT NO. GROUP IT... 11R.��BY Jo CROSS ST. Su Z Lana - /{,D G CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �J 0 DESCRIPTION COMPENSATION INSURANCE' Lor No BLocK MAP HIGHWAY } No a� (CIRCLE) STATE MAJOR SECON ,LOCAL d 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 SIZE OF LOT EXISTING BLDG I �� 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 J. eWNERMiZton Seidner U so as to become subject to the Workers' Compensation Laws AIL OCCUPANCY GROUP tL DDRESS2055 Joshua Tree Lane a Date Applicant N NOTICE TO APPLICANT If, after making this Certificate of CITY PaZm S rin S NO 285- 7131 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 EJ GEOLOGY INSPECTION 0 No Spec. Knowl. ❑ deemed revoked a LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 REq'D O PROVIDED D License Number Lic Class _ LIMITED TIME USE Contractor Date DATE DATE aFROM 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 sl NATO E iness and Professions Code) FINAL APPROVAL _ V.PrfSENT USE OF BUILDING Em t 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) SPACES PROVIDED �1� 21k❑ 1, 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) # •'• . • g'gP POSED USE OF BUILDING Bookstore CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Q 2- 1 3_$Jr 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 ordman es and State laws relating to building construction, TOTAL FEE .y r y� and h eb authorize re sentatives of this County to enter .Z3( QC/ U h abov ntlo d property for Inspectioi purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of V/ ttee bate WORKERS'COMPENSATION DECLARATION CE 875 (2-80) L J 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 certified copy thereof(Sec 3800,Lab C.) Policy No Company FOR APPLICANT TO FILL IN BUILDING c� • - ADDRESS J ❑ Certified copy is hereby furnished BUILDING �7 LOCALITYZA T� ❑ "ADDRESS L J / ' Certified copy Is filed with the county building Inspection LocALiTNEAREST Ross Tdepartment. 61 a Date Applicant NEAREST `�`��/I A DISTRICT NO GROUP TYPE PROCESSED BY CROSS 3T. J L �`��j �li'� �� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d COMPENSATION INSURANCE DESCRIPTION LOT No. I.L.C. MAP .y�� ( IRCLE) } No (7S CIRCLE STATE MAJOR SECOND LOCAL a NO OF BLDGS USE ZONE SPECIAL CONDITIONS O (This section need not be completed if the work involved TRACT �! Now ON Lor U by the permit is for one hundred dollars ($100) or less.) USE TI �' 3 �• SIZE OF LOT EXISTING BLDG J ,I certify that in the performance of the work for which this Q permit is issued, I shall not employ any person in any manner WNERf- so as to become subject to the Workers' Compensation Laws '"•r AAIL - �J //�� /��jJ� OCCUPANCY GROUP U DDRESS y.SOo /_ • •1�JC.i�L .�'•I�� /' '� N Date Applicant NOTICE TO•APPLICANT If, after making this Certificate of V ITY 'e-0 S.82"4 TEL' 2-6S7-W'3,/ 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 GEOLOGY INSPECTION deemed revoked ❑ ❑ 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 E:= PROVIDED D License Number Lic 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' mess and Professions Code) FINAL APPROVAL RESENT USE OF BUILDING +/ LIc.or Reg No Date V / U HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affum that- I am exempt from the Contractor's 2 5 0 R O p' License Law for the following reason (Section 7031 5, Busi- _ ness'and Professions Code) NO. PARKING ❑ SPACES PROVIDED #,o'o O O 4 0 1, as owner of the property, will do the work and the structure Isnot Intended or offered for sale (Section o o D o o D'D 7044, Business and Professions Code) • ROPOSED USE OF BUILDING OIC'0 4—O 1 CONSTRUCTION LENDING AGENCY U V 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 PERMIT FEE I certify that I have read this application and state that the above nformation is correct I agree to comply with all County ISSUANCE FEE ordi s aWeilrre-d laws relating to building construction, TOTAL FEE Kndr b epresentatives of this County to enter ha h property for inspect n pui Uses. SEE REVERSE FOR EXPLANATORY LANGUAGE Sr7 at i ure of Permittee ate '