Loading...
HomeMy Public PortalAbout9137 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION E 875(11-84)a CMISCELLANEOUS APPLICATION •- CE 87 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 -o (See. 3800, ab.C.)]-�'`A //�{� Policy,,No.� aCompanyyJ [ILL7�6t�(W I TO FOR APPLICANT TO FILL IN BUILDING J a ADDRESS Certified copy is hereby furnished. BUILDING. ,9I r VE ADDRESSLA$ UtAA$ LOCALITY Certified opy is filed with t e my building inspection LOCALITY NEAREST depa e P CROSS ST. Date d Applicant NEAREST DIS ICT CCjjll0��. G U TYPE �� PRO SSED Y if VCROSS ST. `„O /1f,/ CONST. \ / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL vO alY1. _ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY rvo, (CIRCLE) STATE MAJOR SE OND OCAL 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 ($100) or less.) usE of SIZE OF LOT EXISTING LDG. Q � Off-. I certify that in the performance of the work for which this _ o permit is issued, I shall not employ any person in any manner OWNEVr&A so as to become subject to the Workers' Compensation Laws. /� OCCUPANCY GROUP �J MAIL I� /I.I,A/liv `�/,p1 Q ADDRESS l/IVlIr11�/•'/'IIpV ✓�1'�VR C~,y Date Applicant //�� pp LLJ NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL _ �� Vy�9p OCCUPANT LOAD913 Exemption, you should become subject to the Workers' z APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTIONEl No Spec. Knowl. deemed revoked. � Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) Of Division 3 of the Busi- SAFETY PERMIT (LIST ITEMS BELOW NO. OF EXITS ness and Professions Code, and my license is in full force and / �1 effect. Sti PARKING SPACES REq'D o PROVIDED I .J License Number Lic. Class A&)TO � LIMITED TIME USE Contractor Date DATE DATE EJI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OFNO'. OF- INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. C� �� STORIES SIGNATURE inessand Professions Code). FINAL APPROVAL_ ,' Lic.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION No. 04 ExI TING BUILDINGS 7$�_a 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- _/910 ness and Professions Code): NO. PARKING 0011}'—= =�' `I F � I, as owner of the property, will do the work and the SPACES PROVIDED rQZr 4.61 1 AM 9:04 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING e I hereby affirm that there is a construction lending agency 4Alvw 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 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 auth rite representatives of this County to enter TOTAL FEE upon the abo - oned property for inspection urp ses. GO atSEE REVERSE FOR EXPLANATORY LANGUAGE Signure of Permittee Date [. •WQ1 ERS'COMPENSATION DECLARATION 76 44 (2-80) MISCELLANEOUS APPLICATION Iyhereby 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 11 ADDRESS ❑ Certified copy is hereby furnished. 4. BUILDING ' LOCALITY .. ADDRESS al .. �'Lc C�>M. ❑ Certified'copy is filed with the county building inspectionNEAREST department. iocALlTv�� ` �'�` CR sT. , Date Applicant EAREST f DISTRICT ffJJ�p GR UP TYPE .PRO ED BY. So CROSS ST. /IY CONST.., / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BOCK COMPENSATION INSURANCE LMAP IG-Ay } NO. (CIRCLE) STATE MAJOR SE D LOCAL a NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) USE OF �/yI / SIZE OF LOT EXISTING BLDG. 1 l cc I certify that in the performance of the work for which thislV/ VVV O permit is issued, I shall not employ any person in any manner WNER .�1L0 �jU so as to become subject to the Workers' Compensation_Laws. OC UeANCY GROUP AWAILLU DDRESS LIE d Date Applicant O S TEL' OCCUPANT-LOAD Z NOTICE TO APPLICANT: If, after making this Certificate of NO. 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 NO Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION occuawrvcr INSPECTION Panic OeVIC2S ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW( NO. OF Exlrs ❑ 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 O � License Number Lic.Class LIMITED TIME USE Contractor' Date DATE DATE FROM: T O: ❑ 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). P SENT USE of BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING B NGS z 2 5 9 1;A ON.LOT AND USE I hereby affirm that, I am exempt from the Contractor's 0 0 • o 0 0 o z License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): SP PARKING 0 a05-85 SPACES PROVIDED - ❑.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). a�� ......SE OF BUILDING �i/�1•Y1^^ •p , Q. 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.). Lender's Name PROPOSED MAX. OCC. (�1 Lender's Address PERMIT FEE I certify that 1 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, TOTAL FEE an hereby authorize representatives of thi County to enter u on the above-mentioned property for ipec Ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION,DECLARATIONCE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY IOF LOS ANGELES BUILDING AND SAFETY DIVISION- i4ure,;or a certificate of Workers'Compensation Insurance,or . a certified copy thereof(Sec.3800,Lab.C. y P FOR AP ICANTTO FILL. N AUDRE s Policy No. Company ' ❑ 'Certified copy is hereby furnished. BUILDING.' Mmos LOCALITY ✓v ❑ • ADDRESS - i Certified copy is filed with the county building inspection CM NEAREST � . department. LocALIrYrCROSS ST. Date Applicant NEAREST •� DISTRICT ,,�LL�}+++ G U--P'''')) TYPE / PRO SED BY CROSS ST. V" ��/ i / ._CONST.', CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1 o ` V COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK, MAP HIGHW V - - _ NO. (CIRCLE) STATE MAJOR SEJOND,LOCAL a (This section neeNO. OF BLDGS... d not be completed if,the work involved TRACT. Now ON LOT USE ZONE' SPECIAL CONDITIONS UO 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 thisO permit is'issued, I shall not employ any person in any manner OWNERSh "Ow ' Q* U so as to become subject to the Workers'-Compensation Laws. MAIL �0 OCCUPANCY GROUP o W. . _ .ADDRESS Date Applicant TEL. NOTICE TO APPLICANT: If, after making this Certificate of clrr� ey NO. OCCUPANT LOAD Exemption, you should become subject to' the Workers' APPLIC- ION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- Wlthcomply with SllCh'provisions OC this permit Shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. ❑ No Spec.,Knowl: ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic OeVICeS El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BEk.ow) a 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 PARKING:SPACES SPACES' REO'D O PROVIDED D Licenge 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 slzE O'FNo OF INsp CTOR'S acting in my professional capacity (Section,7051, Bus- EXISTING BLDG. ' ®a _ STORIES O' - SI ATURE iness and Professions Code). 4 PRESENT-USE OF BUILDI FINAL APPROVAL Lic.or Reg.NO. Date HOME OWNER-BUILDER DECLARATION ON LOT AND UUSE NO. of Exis BUILDINGS USE - I hereby affirm that, I am exempt from the Contractor's r License Law for the following reason (Section 7031.5, Busi- ness and PTOfessions Code): SPACES PROVIDED II . ❑ 1,_as owner of the property, will do the work and the ; structure is not intended or-offered for sale (Section ) illi ;246 1,9 A- 7044; Business and Professions Code). PROPOSED USE OF BUILDING. .rs • • 8'8 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency IS4 1 e e e a o 0.42 for -the ,performance of the work for which this permit is ' issued(Sec. 3097,Civ.C.). Q. Q 9=$6 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 corre t.I agree to comply with all County ISSUANCE FEE, ordinances,and State I s relating to building construction, TOTAL FEE and hereby authorize rese tatives of this County to enter up above-me i ned ;operty for inspect o purp j� SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of k&Aittee tate ` WORKERS'COMPENSATION DECLARATION CE 875 111-84) MISCELLANEOUS APPLICATION • - CE 875 r t 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �ILfIt 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 ADDRESS l'3 Certified copy is hereby furnished. BUILDING j Z. S LOCALITY' XX ADDRESS L EJ Certified copy is filed with the county building inspection LOCALITY -T �Q C'� I NEAEST department. cRosRS ST. Date Applicant NEAREST DIST R IC NO. GRO P TYPE CESSED BY CROSS ST. �7 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LF_GAL o COMPENSATION INSURANCE DESCRIPTION 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.) USEOP SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manneyX OWNER of buildingUCS so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP MAIL XXW�� ADDRESS ©� L -S c�.S U Date Applicant C TEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of clrY No. Exemption, you should become subject to the Workers' APPLICA_ION 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 1 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 Exlrs ness and Professions Code, and my license is in full force anix effect. Name of business PARKING ` SPACES REQ'D E== PROVIDED License Number Lic. Class H L-ZhOq , LIMITED TIME USE Contractor Date DATE DATE 1 am exempt from the licensing requirements as 1 am a FROM: TO: ' licensed architect or a registered professional engineer SIZE OF NO. OF INS CTO S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sl NAT RE iness and Professions Code). FINAL APPROVAL - _ q 7_ PRESENT USE OF BUILDING l Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS n3_7-q ON LOT AND USE I hereby affirm that l am exempt from the Contractor's r`•U\ License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING EJ1, 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 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.). I' Lender's Name 't PROPOSED M'AX. OCC. Lender's Address PERMIT FEE '1•' I certify that I have read this application and state that the 25-001. 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 25 - 0& up n the -mentioned property for inspection urposes. . I r r / SEE REVERSE FOR EXPLANATC)RY:EANGUAGE XX X (1,-1 �J Signature of Per ittec Date l