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Home My Public Portal About9135 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISIO insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ( a Certified co is hereby furnished. BUG s copy y fihd 'LOIN ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP:, TYPE .y PRDCESS`gD• BY CROSS ST. ! �- tt d CONST. IOCAL CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK m^r HCIREIO HWCLA NO. ( Y STATE MAJOR SHCOND ) NO. OF 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 ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. U I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP u.- ADDRESS - r Date Applicant Q NOTICE TO APPLICANT: If, after making this Certificate of CITY No` (• _ OCCUPANT LOAD a Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: compensation provisions of the Labor Code, you must forth- ❑ with comply with such provisions or this permit shall be TRAILER use GEOLOGY INSPECTION deemed revoked. No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONia Panic Devices I hglreby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (ommencing with Section 7000) of Division 3 of the Busi- NO. of EXITS neo and Professions Code,and my license is in full force and eftCt. RBq Lam, -:$`^�(' - PARKING SPACES 'D PROVIDED Licinse Number Lic. Class }' LIMITED TIME USE gontractor Date D ATC DA TZ I am exempt from the licensing requirements as I am a FROM: TO: 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). FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING - I� HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS .. { ON LOT AND USE 14 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 [, 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 13u1LDING - 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.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WOR'ICFiRS'COMPENSATION DECLARATION ,•.{ CE8754(1t.84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tG_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. BUILDING IjC- / LOCALITY ADORESfit Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / ^// COMPENSATION INSURANCE DESCRIPTION LOT NO. / BLOCK r MAP HIGHWAY .No. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT IS12 NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this bt o permit is issued,I shall not employ any person in any manner OWNERQ� "MV so as to become subject to the Workers' Compensation Laws. MAILof a f+ '` �s �—� 5 OCCUPANCY GROUP o ADDRESS Date Applicant / L�LI NOTICE TO APPLICANT: If, after making this Certificate of cITYA/ rl-N r_ el-T y TEL C a 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 INSPECTIO 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 1 , PARKING effect. REQ'D PROVIDED .E� SPACES License Number Lie. Class S u T . 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 IN ECTO R'S acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES I Aru iness and Professions Code). ' PRESENT USE'OF BUILDING A u1��/ � FINAL APPROVAL Lie.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 structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE OF BUILDING 4 e- 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.). t.,,I r i7 Lender's Name , CD ,w•i PROPOSED MAX. OCC. 3 Lender's Address 'I certify that I have read this application and state that the PERMIT FEE r„w= above information is correct.I agree to comply with all County ISSUANCE FEE I L ordinances and State laws relating to building construction, r ` and hereb uthorize repr a tives of this County to enter TOTAL FEE "J upon the " ove-m one erty for inspection purposes. _�, ••x.:l f SEE REVERSE FOR EXPLANATORY LANGUAGE -.10 Signature of Permittee Date Q WORKERS'COMPENSATION DECLARATION CE 875(11-84) 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.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS (( g� ADDRESS (� U M Certified copy is hereby furnished. BODL.%N 135L 3-ril IS eM�lk CIt / ADDRESS LOCALITY i / /,J Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT YJ G TYPE P CES BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR S CON LOCAL NOOF 9LDGS. (This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit /� �� o permit is issued, I shall not employ any person in any manner OWNER( r f Sum d%I'1 � y so as to become subject to the Workers' Compensation Laws. MAIL 'l _ OCCUPANCY GROUP Ot O ADDRESS �! e� t.j v Date Applicant LSI TEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY t �� NO. K, �� -316 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 0 GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION occuawNCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (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 �} /�) I� (�� / effect. arfV V I �'/ PARKING� SPACES REQ D PROVIDED License Number 'Lic. Class V 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 GNATURE inessand Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING 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 SPACES PROVIDED 3'38 �,�—.` I, as owner of the property, will do the work and the t+� `(i J a SLI structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING h 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.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address /1 U 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 0S upon theVve-m property for inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE Signat e of Permitte Date o, l _ WORKERS' COMPENSATION DECLARATION 8 CE 111-aal M ISCELLANEOUS APPLICATION � cE a7s I hereby affirm that I have a certificate of concent tcY.self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ' insure. or a certificate of\'v'orkers'Compensatiorfinsutance.or �I a certified copy thereof iSec. 3800.Lab.C.I. Policy Vo. _Company BUILDING n FOR APPLICANT TO FILL IN bDDRE:SS �✓✓ �G+7 LC. Certified copy is !hereby furnished. X BUILDING LOCALITY ADDRESS �• L, ! I Certified copy is tiled with the county building inspection LOCALITY❑ NEAREST department. Temple City CROSS ST. Date .applicant NEAREST '.DISTRICT NO/ GRO P TYPE P CESSED BY CROSS ST. #.j''�a (CONST. ` CERTIFICATE OF E\EMPTION FROM �.',ORKERS LEGAL L_ (' J COMPENSATION INSLRAN1.1_ DESCRIPTION LOT NO. (BLOCK ;NOAv .1-AY STATE MAJOR SECOND LOCAL (CIRCLE) ( NO. OF BLDGS. (This section need not he completed if the work involved TRACT NOW ON LOT JUSE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars (51(101 or less.l E of i I SIZE OF LOT I EXISTING USBLDG I certify that in the performance -, -lie .vorl: .'or which :his — permit is issued. l shall not employ any person in anw manner owNER so as to become Subject to tlhe `,%orkers' Conipensation Laws• CCU N, GROUP — AAIL ADDRESS � _ r 1 Date Applicant NOTICE TO APPLICANT: It, atter making :!his Certificate of $I=r L _ S—/_2 � OCCUPAN- LOAD Exemption. you diould become subiect :o the Worke-s Compensation provisions of the Labor Cade, you must forh- I APDLICATiON CCR =X!T HARCIAIAPE with compiy with <uch crovisions or :his ^ernlii shall be) _- -RAILS? USE GEOLOGY :NSP=CT!ON NO Spec. 10C%vI, deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY IN SPE CT.IONgg Panic Devices I hereby ;ufirm :hat I am licensed under pICyls]Cns Cl C;laptei SAFETY PERMIT (LIST ITEMS BELOW) a ! 9 (commencing with Section 000) of Division 3 JI the Busi- NO. OF EXITS ness and P-ofessions Code. and my license is in 1ii-I force and effe .. PARKING REO'D I PROVIDED T License Number Lic. Class C'- �``- 'G ��- -/ ..TE' - LIMITED TIME USE w Contractor Date I am exempt from the iicensins requirements as I am a I licensed architect or a registered professional en_eineersrzE of No. of INSPECTOR S z acting n mw professional _apa''it', �e.:ion Il I. Bill'- EXISTING BLDG. S'ORIES 5 NATURE inessand P-ofessicns Code). JPRESENT USE OF BUILDING FINAL APPROVAL Lic. or Reg. No. Date �/ Z` S z 1 "T�i HOME O NER-BI-ILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's V 1 1 License Law for the following reason !Section 7,031.=. Busi- ness and P-ofessions Code): NO. PARKING A� 1, as owner of the property. will do the work and tileSPACES PROVIDED (I strucalre is not intended or offered for sale !Section 1 7044.Business and Professions Code). CONSTRUCTION LENDING .AGI-NC1' PROPOSED USE OF BUILDING I hereby_ affirm that there is a construction lending ❑aency 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 building construction, and herebv a orize pres •tives of this County to enter TOTAL FEE 25.00 _J 1 upon the ab merit' led r rty for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE 3 Signature of Permittee Date S .. WORKERS' (0",11'ENSAI-ION DECLARNHON L.611.11 MISCELLANEOUS APPLICATION :20-0063DPW 12:90 I hereby affirm that I have it certificate 111' consent to scIf COON'FY OF LOS ANGELES BUILDING AND SAFETY DIVISION Il insure,or a certificate of Workers'Compensation In>urancc, or a certified copy thereof (Sec. 3800. Lab. C.) It Policy No. Company FOR APPLICANT TO FILL IN BUILDING l BUILDING ADDRESS C ./ ADDRESS El Certified copy is hereby furnished. �I�J F - LASTVA S D>F.. LOCALITY I ❑ Certified copy is filed with the county building inspection�( CITY I �� zIP CATY �'�mT NEAREST 1 department. 1 G m DV CROSS ST. DateApplicant SIZE OF LOT NO.OF BLDG$.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. CERTIFICNIE OF EXEMPTION FROM WORKIA-, (TRACT BLOCK LOT NO. �J COMPENSATION INSURANCE NO.,N HIGHWAY(CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work in%ol%'Cd ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS L. by the permit is for one hundred dollars 0+1001 or less.) — I1 certify that in the performance of the work for which this OWNER �eN pF TFL No.�G� permit is issued, I shall not employ any person In ;my it I I i - I so as to become subject to the Workers' Com enation Laws. IAODREss Q9 LAS TUNhS Q?- i :J p OCCUPANCY GROUP r. Date Applicant CITY ZIP NOTICE TO APPLICANT: If. after making this Certificate TEMPLE UTY I ql=" OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forthwith comply with such provisions lir this permit sliall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. No Spec.Knowl. ❑ [ i (— OCCUPANCY INSPECTIONY_lly� Panic Devices ❑ LICENSED CONTRACTORS DEC'LAR,' TION I hereby affirm that I urn licensed Linder provisions of Chapter SAFETY PERMIT O (LIST ITEMS BELOW) F 9(commencing with Section 7000)Of Division 3 Of the Business � NO.OF EXITS a 3 �f and Professions Code,and my license is in full force and effect. PARKING: REQ'D PROVIDED License Number Lic. Class X sN:cEs Contractor Date CLAW jj AVI -_W (�(v _ LIMITED TIME USE DATE DATE ❑ 1 am exempt from the licensing requirements as I am it 1 FROM: TO: licensed architect or a registered professional engineer I i INSPECTOR'S f I 'SIZE OF NO.OF acting IIT Ill)' pr011'titiIl111i1I L'apill,'lly (�Cellllil 7011, ICIISInI'SS SIGNATURE +EXIS TING I3LUG. SiORIL:S D and Prolcssions ('ode). LIC. or Reg. No._--_ Date _ ��PRESENT USE OF BUILDING F114AL APPROVAL 6EAU i SALON HOME OWNER-BUILDER DI'J1AR.AII0N IND.OF EXISTING BUILDINGS ON LOT AND USE hereby affirm that I ant exempt from the C'ontractor's Liccose Law for the following, reason (Section 7031.5, Business all(] — Professions Code): NO.PARKING SPACES PROVIDED ❑ Las. owner of III'_ properly. \\ill dl, the �Lork and IIIc — ��t�V SALON al ^A' Structure IS not i�} endcd UI' 01IC1'CLI fol sale (Section /II-I-1. PROPOSED USE OF BUILDING V 1-1 t.O `F I Business and Pyre: ions Code). I CONSTRUCTION (-ENDING AGENCY hereby affirm that there is a ConSlruction Icnding agCIIQ for _ the performance of the work lir lvhich this permit is issued (SCC. 3097,CIV.C.). PROPOSED MAX.OCC. IJ Lender$ Name . ..-_-_.. ..- ..____.. APPLICANT(PLAINT)Si iE. TEL NO. X >= Lender's Address -.._.... ADDRESS i I certify that I have read this application and state that the I (9lq g• DO N AVE. SW 4(A131kE1- 1 above information is correct. I agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. '>✓[ I A TOTAL FEE ID M OI SFE REVERSE FOR EXPLANATORY LANGUAGE M O m Id Signatu of Pennittce 1 Uuc LL f \\'ORI:LRS CUMPLNS:\11UN UL.LLaI<a11U1\ ulv875 (11 C4) CE 6%5 MISCELLANEOUS APPLICATION 11 herebr. a certificate 1 have a certificate of consent to ,o COUNTY OF LOS ANGELES BUILIANG :GNU SAFETY IAVISION cure, or a certificate of R`orkers'Compensation Insurance,or certified copy thereof(Sec. 3800.Lab. C.). olicy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS _ Certified copy is hereby furnished. 6UILDING T ADDRESS `'ll'� �- `� (Jti��j ,y� LOCALITY Certified copy is filed sviill the county building inspection NEAREST LOCALITY department. 1< CROSS ST. late Applicant NEAREST ^'I,, r - DISTRICT O. GR'AUP TYPE P ESSED BY CROSS ST. Lom Ua `D y {� CONST.r CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (/ ///ppp+++ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. ICIRCLE) 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 ry the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. certify that in the performance of the work for which this � Q -ermit is issued, I shall not employ any person in any manner OWNER as to become subject to the Workers' Compensation Laws. � � OCCUPANCY GROUP M'-" `-� AD DR E55 �07� w, _ late Applicant k TEL. l_i _ ^7r6q OCCUPANT LOAD IOTICE TO APPLICANT: If, after making this Certificate of CITY NO. I! :xemption, you should become subject to the Workers' x APPLICATION FOR EXIT HARDWARE: ompensation provisions of the Labor Code, you must forth ith comply \with such provisions or this perinit shAl be TRAILER USI GEOLOGY INSPECTION ❑ eemed revoked. U ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION. OCCUPANCY INSPECTION ® Panic Devices hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS ELOW) (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS less and Professions Code. and my license is in full force and f fe ct. tTl�•t�sC� ywePARKING � PROVIDED .icense Number SPACES REO'D Lic. Class LIMITED TIME USE Ontractor Date DATE DATE FROM: 1 am exempt from the licensing requiremenis as I aun a TO: licensed architect or a reuistered professional eneinecr SIZE OFNO. OF INSPECTORS l 'EXISTING BLDG. STORIES SIGNATURE acting in my professional capaeity iSe�tion 70;1. Bus- inessandProfessionsCodel. FINAL APPROVAL S to 4PP.ESEf:T USE OF BUILDING ly .ic.or Ree. No. _ Date _ HOME OWNER-BUILDER DE.CLAk:\TIO\ No. OF EXISTING BUILDINGS (/ / F ON LOT AND USE /l herebt affirm that I ant exempt from the Coniractor"s � y_�i0{I 1 ,'f,1R jt; .icense Law for the following reason (Section 7031.5. Busi- Iess and Professions Code I: NO. PARKING SPACES PROVIDED U- / 1. as owner of the propertp. will do the work and the — structure is not intended or offered for sale (Section 7044.Business and Professions Code). coNSTRurrloN LENDING '\Gr\cY PROPOSED USE OF BUILDING hereby affirm that there is a Construrtiort lending a_'enc.% or the performance of the work for which this permit is ,sued(Sec. 3097.Civ.C.I. .ender's Name PROPOSED MAX. OCC. .enders.Address __ ()(,1 certify that 1 have read this application and state that the PERMIT FEE Ibove information is correct. I agree to comply with all County ISSUANCE FEE )rdinances and State laws .relating to building construction. Ind hereby authorize representatives of this County to enter TOTAL FEE �� G'r Ipon the above-mentioned properq for inspection purposes. SEE RL'VERSI_ FOR EXPLANATORY L.A?iGliAGE SIVIll11Ul'e of Pl'1'II1111CC D;uc .. . WORKERS'COMPENSATION DECLARATION CE 875 i17�84) MISCELLANEOUS APPLICATION {� -- CE 875 (J I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION unsure, 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 y is hereby XXfurnished. BUILDING AD OR ESS LOCALITY ElCertified copy is filed with the county building inspection LOCALITY 6'2 NEAREST department. ][y, cwoss ST. Date --_Applicant NEAREST DISTRICT NO. 'ROW ITYPE P EESSED BY CROSS ST. / CONST- CI---R IIFIC;\'I'E OF EXEA1PTlON FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAPHiD Hw Ar NO. (CIaCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (]his section need not be Completed of the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG. > I certify that in the performance of the work.for which this — D- n permit is issued, I shall not employ any person in any manneXX OWNER of building so as to hecome subject to the Workers' Compensation Laws. — OCCUPANCY GROUP R' MAIL C AD OR ESS Applicant--- L No-ria, TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD v. 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 peri-nit shall be TRAILER USE I] GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. I I(•LLNSFD CONI RACfORS DECLARATION OCCUPANCY INSPECTION Panic Devices i hereby atitrn 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 aIX !Na Of business PARKING r� Cllect. SPACES REQ•O ' I PROVIDED t.ic,nse Nomber ___--_---- -- ._ Lic. Class '��GL` —� LIMITED TIME USE (ontrnctor..--..... -_--- ----- Date _ DATE DATE F4OM: TO: 0 1 am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF No. OF NSP NATURE' acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES inessand Professions Code). F!NALAPPROVAL _l f PRESENT USE OF BUILDING Lic.or Ree. No. -_-___-- ----_—_--- Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 'n ON LOT AND USE /� ? i,i}.ii.-i-•f•_ii„��','i .- - . I hereby affirm that I ani exempt from the Contractor's 3 5 License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): No. PARKING ES-PROVIDED I, as owner of thSPAC e property, will do the work and the , structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONST RUCTION 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 Nanne PROPOSED MAX. OCC. I.ender's Address'-.-- _.---_. -- 1 certify that I have read this application and stale that the i PERMIT FEE 00 � above information is correct. 1 agree to comply with all County I ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25. 00 upon the above-nnentioned property for inspection purposes. - ! SEE REVERSE FOR EXPLANATORY LANGUAGE 'XX XX