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Home My Public Portal About9139 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 a s4(t i-aa) M � „ ��-� Q APPLICATION I hereby affirm that I have a certificate of consent to sett' 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 APP LI CANT TO FILL IN BUILDING �j� ADDRESS Certified copy is hereby furnished. XBUILDING Jaktjj LOCALITY I ADDRESS L El Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEARESTLois o� DISTRICT NO. GRITYPET. PROUPSSED BY CROSS ST. LCONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL f� 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.) USE OF n SIZE OF LOT I EXISTING BLDG. d 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 X OWNER 51' so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP hMAIL � j� /' O ADDRESSI 5 /y" / li ;. Date Applicant w � � � A TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY No. z Exemption, you should become subject to the Workers' APP ICATION 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. OCCUPANCY INSPECTION ❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions o£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 i t ;t effect. PARKING SPACES REO'D PROVIDED License Number Lie. Class AM-CA LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ElI am exempt from the licensing requirements as I am a licensed architect or a registered,professional engineerSIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL .ppp V Lie.or Reg.No. Date PRESENT USE OF BUILDING ,\ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 0 �\ —z_I+ er License Law for the following reason (Section 7031.5, Busi- NO. PARKING, ? +''' j�••,-I `f `--�Y ness and Professions Code): I, as owner of the property, will do the work and the SPACES PROVIDED 11 -,=;, 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 Peat FS RC 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 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 uponthe� ove=entioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si atur of Perm tee V Date ;WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION J� CE 875 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.C.). _ Policy No. Company FOR APPLICANT TO FILL IN BUILDING �y ADDRESS Certified copy is hereby furnished. ADDRESS -/ J37 Las T�n/a S PY• LOCALITY Certified copy is filed with the county building inspection OcwLITY —f E-111 t� NEAREST department. C CROSS ST. Date Applicant AREST DISTRI�T`NO/ GROUP TYPE PROC ES SED BY ROSS ST. /V f/t OI 55 WWW{{(( /✓J�/)V' CON SZ. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY rvo. (CIRCLE) STATE MAJOR SE CO D 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 S E OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this o 11�-J J permit is issued, I shall not employ any person in any manner OWNER 2 Lt€� G((C—AJ . so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o rAD RESS ,r�YRRIV 0.140 0Date Applicant iI NOTICE TO APPLICANT: If, after making this Certificate of P, /3®�/� NO �sl8� �{�I—koy 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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. 0 deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0 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 SPACES REQ'D PROVIDED License Number Lie. 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 SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING G� 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 G 8 9 9.9 A 1, as owner of the property, will do the work and the SPACES PROVIDED Z structure is not intended or offered for sale (Section 0 0.'0 0.-88 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 0 0 0_8 8 I hereby affirm that there is a construction lending agency Q for the performance of the work for which.this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. r (J Lender's Address o j i V PERMIT FEE J� I certify that I have read this app' ation and state that the 1 u above information'�orrect.I agree comply with all County ISSUANCE FEE ordinances and tate laws relating o building construction, Da and hereby a orize re senta ' of this County to enter TOTAL FEE p the ab e-mentio ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE na re tee Date i 11