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Home My Public Portal About9122 LAS TUNAS DR_Miscellaneous__ r WOkKERS'COMPENSATION DECLARATION CE 875 (11-84) M I SC E L LA N EO U S APPLICATION CE 875 L, ) L hereby affirm ;that I" have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IIL JII insure, or a;certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). �� m Policy No. Company FOR APPLICANT TO.FI LL IN BUILDING avZ S� ADDRESS �• Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY. Certified copy is filed with the county building inspection LOCALITY f j/ NEAREST01 department. zam `�� t/,�+>S CROSS ST. Date Applicant NEAREST DISTRICT NO. I G UP" TYPE P ESSED BY CROSS ST. 4a,424 CONST. // CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o P COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLOGS. (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by tfie permit is for one hundred dollars ($100) or less.) USE of 07 I certify that in the performance of the work for which this srzE of Lor E ISTING BLDG. CD permit is issued, I shall not employ any person in any manner OWNER d� �Ul ccJti'�i. ' 1 0 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP a Date Applicant App p�� C_3. �j� _ �� NOTICE TO APPLICANT: If, after making this Certificate of CITY C ITvoL��/�� OCCUPANT LOAD yt Exemption, you should become subject to the Workers' C� z Compensation provisions of the Labor Code,.you must forth- /dlcJAPPLICATION FOR EXIT HARDWARE: 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 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 _P1 Lr5 n e effect. PARKING SPACES � ROV REQ'D PIDED License Number Lic. Class LIMITED TIME USE Contractor Date — ! - DATE DATE FROM: TO: El I am exempt from the licensing requirements as lam a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES f5TREU iness and Professions Code). FINAL APPROVAL ��_z " PRESENT USE OF BUILDING ' Lic.or Reg.No. Date "'wev NCI EEE HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE q I hereby affirm that I am exempt from the Contractor's I0•/�� License Law for the following reason (Section 7031.5, Busi- / ,ip 091010-0001 71126/935 ness and Professions Code): NO. PARKING ------ --" s r v 3 - �tyiv 1, as owner of the property,.will do the work and the. SPACES PROVIDED f til 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 agencySg� 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 O � . 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 representatives of this County to enter TOTAL, FEE C90 upon the above-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE " Signatur f Permittee Date I R'ORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION 1 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 l , ,,certified-copy thereof(Sec. 3800,Lab.C.). WW I Policy No. Company FOR APPLICANT TO FILL IN ADDRESS G �a z� L � Certified copy is hereby furnished. XX BUILDING ,CC ,7� LOCALITY ADDRESS !^4 7 UAJA,,) f ❑ Certified copy is filed with the county building inspection I LOCALITY NEAREST department. 3vx rt 04 foe F GjT Ross ST. Date Applicant NEAREST ) � DISTRICT NO. GR UP TYt�z ;�CESSED BY CROSS ST. S 1.11✓'T��1� /1 ( CO CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / O COMPENSATION INSURANCE DESCRIPTION LOT NO. 5 BLOCK MAP HIGHWAY "G. (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, I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. N� �/ D_ D permit is issued, I shall.not employ any person in any mannek;, OWNER Of b uilding f tLAJ A Q ' sp as to become subject to the Workers' Compensation Laws. MAIL I OCCUPANCY GROUP D#1 n DateApplicant��l ADDRESSt7ov L MOx1A V-0 2a NOTICE TO APPLICANT: If, after making this Certificate of CITY(, MCI TG NO. Z�2j•3 g�- 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 rovisions or this permit shall be ❑ ❑ No Spec. Knowl. P Y P P TRAILER USE GEOLOGY INSPECTION deemed revoked. LICENSED CONTRACTORS DECLARATION occuPANcr INSPECTION ❑ Panic Devices I hereby affirm that 1 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 arrA - effect. Name Of busdneSS SPACESG REQ'D E:= PROVIDED License Number Lic. Class �G/ 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. Z STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDINFINAL APPROVALG Lic.or Reg.No. Date / ,✓B��i 1 HOME OWNER-131JILDER 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 70.31.5, Busi- ness usi ness and Professions Code): NO. PARKING 1, 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 USE OF BUILDING 1 hereby affirm that there is a construction lending agencya for the performance of the work for which this permit is �' � ZCei 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 —25 - 00 above information is correct. I agree to comply with all County ISSUANCE FEE "i 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 properW fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ �X Sig Z,re of I' rrnitt c Date