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Home My Public Portal About9090-9092 LAS TUNAS DR_Miscellaneous__ t WORKERS'COMPENSATION DECLARATION 76M444 CE 8' t,-8 I MISCELLANEOUS APPLICATION 1 I rebaffirm ihat 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 LJ ,I ! a certified copy thereof(Sec. 3800,Lab.C) -J I 42 Policy No. CompanyFOR APPLICANT TO FILL IN AOUILDING DDRESS 90rJ0 Certified copy is hereby furnished BUILDING Z�7 ADDRESS 'je5 LOCALITY ( ) Certified copy is filed with the county building inspection LDcauTYl department / �j NEAREST CROSS ST 04 Date Applicant NEAREST DISTRICT NoGROOO,,, P TYPE CESSED BY CROSS ST !Oi /�( CONSTI�. Jr ` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O'/J /d- I// COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCKnoP (oGiRHWAY C E) 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 (5100) or less.) USE of I SIZE OF LOT EXISTING BLDG - 7- I certify that in the performance of the work for which this _= permit is issued, I shall not employ any person in any manner X OWNER v ,-j LLe-ON- so as to become subject to the Workers' Compensation Laws 4 /yy ��/p OCCUPANCY GROUP MAIL / ! /"T� 17—VIP-71-09 S /`i ( ADDRESS � Date Applicant /e TEL�...�I 6-116 - NOTICE TO APPLICANT If, after making this Certificate of CITY C No /�/o OCCUPANT LOAD =- 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. ❑ ❑ No Spec. Knowf. N LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONS Panic Devices M 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 N SPACES REgD PROVIDED o License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE w I am exempt from the licensing requirements as I am a M ! licensed architect or a registered professional engineer SIZE OF No OF F�DM To INSPECTORS Z acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNA RE mess and Professions Code) oFINAL APPROVAL PRESENT USE OF BUILDING U Lic or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS /,{� ON LOT AND USE O %" .7 I hereby affirm that I am exempt from the Contractor's t License Law for the following reason (Section 7031.5, Busi- �O. XI ness and Professions Code) NO PARKING I 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 X PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency kMC V V 9>7 e- for the performance of the work for which this permit is issued(Sec 3097,Civ C.). Ze,^ tA- I Lender's Name PROPOSED MAX OCC Lender's Address ( I certify that I have read this application and state that the PERMIT FEE 25.00 above information is correct. to comply with all County ISSUANCE FEE ordinances and State laws elating to building construction, and hereb autho repre ntatry s of this County to enter TOTAL FEE 25.00 l upon o nt ed pr e for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ature of rmit Date . i t WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION - CE 875(11-84) I hereby affirm that I have a certificate of consent 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 CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS FiCertified copy is hereby furnished BUILDING U^� !' XX ADDRESS lO el Cu I U LOCALITY DCertified copy is filed with the county building inspection LOCALITY �j�M NEAREST �•� 417 department. (?yn a CROSS ST Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CE SED BY CROSS ST -I- CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK M P HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS, HO ICIRCLRI (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.) USH OF !� I I certify that in the performance of the work for which this slzE of Lor EXISTING BLDG. C o permit is issued, 1 shall not employ any person in any manneiyX OWNER of building : /! S >< so as to Become subject to the Workers' Compensation LawsMAIL 607Z OCCUPANCY GROUP ADDRESS 2� N , C U Date Applicant 41 NOTICE TO APPLICANT If, after making this Certificate of CITY �a,n bre NO.L. —�� - OCCUPANT LOAD 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 ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I11Z_ Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT E] (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force anix effect Name of business PARKING �I SPA CHS REp'D E� PROVIDED I I License Number Lic. Class �( f� LL--J LIMITED TIME USE Contractor Date DATE DATE F1I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO, OP IN GN TORS acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES D SIGNATURE iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Llc or Reg No Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USB I hereby affirm that I ani exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code) NO. PARKING „., ElI, 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 PROPOSED USH OF BUILDING 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 - I certify that I have read this application and state that the PERMIT FEE 25 . 00 above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction, and hereby authorize representatives of this County to enter TOTAL FEE 25-00 upon the above-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX �_iC k 6LCUXX Signature of Pernntice Date - WORKERS'COMPENSATION DECLARATION 76M444. MISCELLANEOUS APPLICATION I hea,by affirm that I have a certificate of consent tself CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION mNure, or a certificate of Workers'Compensation Insurance, e,or I• a certified copy thereof(Sec 3800,Lab.C.). Policy No Company FOR APPLICANT TO FI LL IN BUILDING AD CRE33 ,a 90 FlCertified copy is hereby furnished. BUILDING 0 d LO CALITYI XX ADDRESS ��l ElCertified copy is filed with the county building inspection LOCALITY NEAREST department. 3M G .Ross ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P OCESSED BY CROSS ST O� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION Lor No BLD.K 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 l ley I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. GL/C permit is issued, I shall not employ any person in any manned OWNER of buildin g -AAI'd!sQA1 so as to become subject to the Workers' Compensation Laws. MAIL t' tL�y,,� OCCUPANCY GROUP ® � Date Applicant ADDRESS ' N . I/�I/►I OIU G w TEL NOTICE TO APPLICANT: If, after making this Certificate of F CITY f}yy)�j roL FjZ�f �U 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 oI 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 aii*X effect. Name of business PARKING SPACES REp'D D PROVIDED License Number Lie. Class O1 P �J gO10 -9012 tk- T(JNiYS /� LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a nLm C 61 1 o FROM' TO licensed architect or a registered professional engineer SIZE of NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lie or Reg No Date 6 J HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Vfl1� flo J I hereby affirm that I am exempt from the Contractor's ON LOT AND USE t �� License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING J I, as owner of the property, will do the work and the SPACES PROVIDED r structure is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED use of BUILDING 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 t PROPOSED MAX. OCC. - Lender's Address I'{ PERMIT FEE I certify that I have read this application and state that the 25 . 00t above information is correct I agree to comply with all County ISSUANCE FEE ;1 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25- 00 `� upon the above-mentioned property for in pection purposes �- EE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date `'