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Home My Public Portal About9087 LAS TUNAS DR_Miscellaneous__ WORKERS' COMPENSATION DECLARATION 200063DPW12/90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION •rinsure,or a certificate of Workers'Compensation Insurance,or a a certified copy thereof (Sec 3800, Lab.C) ;= Policy No Company FOR APPLICANT TO FILL IN BUILDING BUILD' INpG ADDRESS ADDRESS ❑ Certified copy is hereby furnished g QO 7 e. L/95 71,w1?•g 0;1 LOCALITY ❑ Certified copy Is filed with the county building Inspection CITY �Y ZIP �/T 9� department yFjryrPG� / / O NEAREST CROSS ST. Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY Q CERTIFICATE OF EXEMPTION FROM WORKERS' CONST. TRACT BLOCK LOT NO. MAP HIGHWAY I COMPENSATION INSURANCE (This section need not be ASSESSOR MAP BOOK PAGE PARCEL completed if the work involved NO (CIRCLE) STATE MAJOR SECOND LOCAL � by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS I certify that in the performance of the work for which this �orf er permit is issued, I shall not employ any person in any manner �'HBLD <<—`_77C i�orrlE TEL No. so as to become subject to the Workers' Compensation Laws ADDRESS a OCCUPANCY GROUP Date Applicant CIT ZIP — t NOTICE TO APPLICANT If, after making this Certificate f'�C��.� CI�' F/00 of Exemption, you should become subject to the Workers' OCCUPANT LOAD Compensation provisions of the Labor Code,you must forthwith APPLICATION FOR EXIT HARDWARE. l comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Krtowl ❑ revoked P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) I I 9(commencing with Section 7000)of Division 3 of the Business SIDe o us tress NO OF EXITS and Professions Code and my license Is in full force and effect PARKING• REO'D D PROVIDED License Number Lie Class &-4S M-7-E- U,��iUeE C� SPACES t i i t Contractor Dae LIMITED TIME USE � b'� ►/� ❑ I am exempt from the licensing requirements as I am a DATE DATE 3 licensed architect or a registered professional engineer FROM To acting in my professional capacity (Section 7051,Business SIZE OF NO OF INSPECTOR'S and Professions Code) EXISTING BLDG. STORIES SIGNATURE. LIC or Reg No . Date PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS I ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 70315, Business 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,XPROPOSED USE OF BUILDING 5 2— Business and Professions Code). t � � � �il/�v Cii9G �� cJ�►p� - 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) PROPOSED MAX.OCC Lender's Name APM PRIN rl &S a 86.E 73 Lender's Address ADDRESS !J ( � I I certify that I have read this application and state that the �� rS7' above information is correct. I agree to comply with all County PERMIT FEE ordi ce and State laws relating to building construction,and h yby a ttorize r ive of this County to enter upon ISSUANCE FEE i he ab - nti d rt for inspection purpo es. j I // �( TOTAL FEE (( U3 SEE REVERSE FOR EXPLANATORY LANGUAGE • i. S,_natur nrimee atm --:WOI ERS'COMPENSATION DECLARATION CE 875 (11-84) V �SC E L L A AE OJ S 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 "fl arcertified copy thereof(Sec 3800,Lab Q. , Policy No Company FOR APPLICANT TO FILL IN BUILDING (09 / ADDRESS `-''0�I unas pr Certified copy is hereby furnished BUILDING / _ as LOCALITY �1 ADDRESS DCertified copy is filed with the county building inspection LOCALITY al NEAREST h department. Le CROSS ST. N. Date Applicant NEAREST DIS R T O. Gjjj��UP TYPE PR ESSE BY CROSS ST T.Iff CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR S CO ND LOCAL NOOF BLOGS. (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.) ry y USE OF C SIZE OF LOT 5V X 125 EXISTING BLDG. Sa 2 7"' I certify that in the performance of the work for which this SD_ C!) permit is issued, I shall not employ any person in any manner OWNER ndi a hq C> so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP MAIL ADDRESS O ` W v �, � O Date Applicant LL NOTICE TO APPLICANT• If, ter making this Certificate of CITY s�� No� Z '�� OCCUPANT LOAD z Exemption, you should beccfine subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of t e Labor Code, you must forth- with comply with such pr lsrons or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONT ACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am censed under provisions of Chapter SAFETY PERMIT ❑ LIST ITEMS BELOW) 9 (commencing with Sec on 7000) of Division 3 of the Busi- NO. OF EXITS 3 ness and Professions Co , and my license is in full force and effect. ( �1�g111 PARKING REQ'D PROVIDED SPACES LL��ff License Number Lic. Class S S t �/J/�/� _ LIMIT TIME USE Contractor Date — • DATE DATE PROM- TO I am exempt f om the licensing requirements as I am a licensed archi ct or a registered professional engineer SIZE OF (//� 2 NO. OF SPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG 0750 Tt STORIES I IG ATURE mess and Pro ssions Code) PRESENT USE OF BUILDING cant FINAL APPROVAL Lic.or Reg No. Date / I'/ VL I_VJ_/ I I HOME WNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS , ON LOT AND USE I hereby affir that I am exempt from the Contractor's License Law r the following reason (Section 7031.5, Busi- ness and Prof sswns Code): NO. PARKING !J(I�(]—CI3Of !itlGl� SPACES PROVIDED 0 I, as o ner of the property, will do the work and the X423 1 AN 7013:'- structu a is not intended or offered for sale (Section 7044, usiness and Professions Code). ONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ` I hereby affirm that there is a construction lending agency 1 s halo O I�b 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-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee I Date