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Home My Public Portal About9149 LAS TUNAS DR_Miscellaneous__ WORK;�RS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION {� CE 875 LJ 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 �/L / G� S ADDRESS J'� Certified copy is hereby furnished. BUILDING ADDRESL �-v�� LOCALITY S EJCertified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST 'DISTRICT N G�jOUP TYPE CESSED BY CROSS ST. �? 6( CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a {�P�J Ler COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCKMAP 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 SIZE of LOT EXISTING BLDG. I certify that in the performance of the work for which this CD permit is issued, I shall not employ any person in any manner OWNER 6 �A), T =' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP. � a ADDR Date ESS Applicant °�, �' C R F %lo il u�J NOTICE TO APPLICANT:,If, after making this Certificate of CITY E' NOL �lg-;Z 9T 1&3 y5 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. El deemed revoked. ��/ LICENSED CONTRACTORS DECLARATION occuawncY INSPECTIOI tTl Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT tJ❑ (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 .c effect. � ' l � � PARKING SPACES REQ�D PROVIDED License Number Lic. Class ® �• LIMITED TIME USE Contractor Date Ce' 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 \ SIGNATURE iness and Professions Code). FINAL APPROVAL 1 _1 PRESENT USE OF BUILDING V �� O~ + \\VJJ Lic.or Reg.No. Date �. HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS = _�— FEE 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- )i 41 -° ness and Professions Code): NO.PARKING _" ;�% 7 a SPACES PROVIDED - !-i') ,`S PrP 1..; I, as owner of the property, will do the work and the - i't s= structure is not intended or offered for sale (Section 7044,Business and Professions Code). U 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 f PROPOSED MAX. OCC. •0'" 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 u on the above-mentioned perty f r inspection purposes. �y - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permit Date WORKERS'COMPENSATION DECLARATION CE 87 4(2 SO) = ,� I SC E L LA N E O U S A P P L I C AT I O N 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 j ;.{'„• - Q ADDRESS ❑ Certified-copy is hereby.furnished. DDR ISs �''L / S T�pV'� LOCALITY y ❑ Certified copy'is'filed with the county building inspection- v - - NEAREST . department.' LOCALITY M C- ,I CROSS ST.' Date Applicant-" NEAREST DISTRICiT NO. G UP TV PE PRO SED-BY CROSS ST. -.�� CONST. CE_RTIFICATE OF EXEMPTION FROM WORKERS' 'LEGAL COMPENSATION.INSU RANGE. DESCRIPTIOry LOT NO-1 1 . BLOCK MAP HIGHWAY NO. (CIRCLE.) STATE AJOR.SECOND LOCAL NO. OF BLDGS. t1 (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by.the permit is for otie hundred dollars ($100) or'less.) U . USE OF SIZE OF LOT ti' 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 mannerLDRESS L D p D 7 JN so as to become subject to the,Workers' Compensation Laws. ll / �jy� l 6 OCCUPANCY GROUP f U ��V Le( ..J f / L Date Applicant ^ TEL. /I!f („/ lr -�S OCCUPANT LOADz_ NOTICE TO APPLICANT: If, after making this Certificate ofN rvo. (7 6 rExemption,' 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. Panic Devices y El.LICENSED CONTRACTORS DECLARATION occuPwrvcv INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 1 (LIST ITEMS BELOW) NO. OF EXITS ❑ 94commencing 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 I PROVIDED License 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 SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE oe iness and Professions Code). APPROVAL FINAL z� PRESENT USE OF BUILDING (f'{y /v 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 - ❑ I, as owner of the property, will do the work and the z 4 6.3.9 A structure is not intended. or offered for sale (Section 7044, Business and Professions Code). N # 0 0 o o 88 ROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY �l �� 0 01010 010 o z I hereby affirm that there is a construction lending agency for the performance of the work for which this,permit is 0 8.,1 9783 issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. DCC. - - - 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, TOTAL FEE /a� and hereby authorize representatives of this County to enter (f,� C � up n the above-mentioned property f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /__'�igiiature of Permitte Date >) WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (11-84) M ISCCEL_L� � A N E O°111 �' , A P P L I C A T I O N J� C I here.--,y t afcere certificate 1 have a certificate of consent to self t� insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN 13UILDING :'.DDR ESS41 Certified copy is hereby furnished. BUILDING / �� nns ADDRESS L-r'P 6t LOCALITY Certified p rted copy is f'ed with the county building ir.spection LOCALITY Temple City (.'.Ross 5T. Date Applicant NEAREST 715TRICT N GRO P TYPE P OC E SS ED BY CROSS ST. ��D CONST I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGL COMPENSATION INSURANCE DESCRIPATION LOT NO. BLOCK MAP ..G..Al 1+0. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT ':ISE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF , SIZE OF LOT • E� G 7- i I certify that in the performance of the work for which this lCa. — it is issued, I shall not employ any person any manner so alDwNER so as to become subject to the Workers' Compensation Laws. X OCCUPANCY GROUP ' MAIL ADDRESS Date Applicant NOTICE TO APPLICANT: If, after making this Cert ficate of clTr uoL o�3 Z OCCUPANT LOAD Exemption. you should become subject to the '.Yorkers' _ Compensation provisions of the Labor Code, you rntcst forth- APPLICATION FOR cXIT HARDWARE: with comply with such provisions or this permit shall be TRAILEP USE GEOLOGY INSPECTION deemed revoked. P No Spec. Know(. �I _ --+ OCCUPANCY INSPECTION$$ Panic Devices - LICENSED CONTRACTORS DECLARATIONI I )tereb}° affirm that I am licensed under provisions ot.Chapter SAFETY PERMIT — I LIS' ITEMS 3EL0'RI 9 +commencing with Section 7000) of Division 3 of :he Busi- — No. OF EXITS n i ness and Professions Code. and my license is in full force and / effect. L KINGI PACES REO.O I { I PROVIDED I� License Number Lic. Mass LIMITED TIME USE Contractor Date ' OAT. DATE PROM: TC: I 1 am exempt from the iicensine requirements ca I am i i licensed architect or a registered processional•en;ineer 51ZE OF I NG. cFINSPECTOR'S actin_ in my processional oapacit\ iSe:t10n 7f.`i, BUY EXISTING SLOG. STORIES SIGNATURE c iness and Professions Code). 1 PRESENT USE OF BUILDING �F•INAL APPROVAL I Z7 Lic.or Reg. No. Date r HOME OWNER-BUILDER DECLARATION . NC. OF EXISTING BUILDINGS �iBl3 ON LOT AND USE V 1 hereby affirm that I am exempt from the Contractor t I License Law for the following reason (Section -031..5, Busi- ness and Professions Code): NO. PARKING I. as owner of the property, will do :he tvorl; and the I SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). p A PROPOSED USE OF BUILDING CONSTRUCTION LENDING .AGENCY I Hereby affirm that there is a construction lendir.g agency t 1 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name y� PROPOSED MAX. OCC. Lender's Address I ( I PERMIT FEE 25.00 + !' I certify that l have read this application and state that the I-•It above information is correct. I agree to comply with all County ISSUANCE FEE XMI ordinances and State laws relating to building constauction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 I i i! upon the bove mentio d property fo~•ispection purposes. �• I �`n ', - SEEREVERSE FOR EXPLANATORY LANGUAGE V Q� i•::1 Signature of Permittee Date