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Home My Public Portal About9150, 9150 1/2, 9152 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that 1 have a certificate of consent to self• COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, vr_ ertificate of Workers'Compensation Insurance,or a certified cop7 thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APP LICANTTO FILL IN BUILDING /� I �} n!• ADDRESS (-- Certified copy is hereby furnished. BUILDING C� ADDRESS LOCALITY DCertified copy is filed with the county building inspection LOCALITY NEAREST / department. CROSS ST. In Date Applicant NEAREST DISIC pQtS. /OUP TYPE PRO 55 BY CROSS ST. hJ_ /ly`J /y�/ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 6HW AV No. (CIRCLE) STATE MAJOR SEC 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 SIZE OF LOT EXISTING BLDG. `> I certify that in the performance of the work for which this D_ permit is issued, I shall not employ any person in any manner OWNER OF 131- , ,_ y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP, "�" Date Applicant ADDRESS L®�� D _ C3 LLJ NOTICE TO APPLICANT: If, after making this Certificate of CITY ea r ��- ��_-� 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. Panic Devices 11 LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ El I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the BUSY SAFETY PERMIT ❑ (LIST ITEMS BELOW NO. OF EXITS ness and Professions Code, and my license is in full force and SPACES effect. PARKING REQ'D D PROVIDED • License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF A. 4acting in my professional capacity (Section 7051, BUs- EXISTING BLDG. STORIES iness and 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 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). RP CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING t,x.I , . I hereby affirm that there is a construction lending agency X �r- for the performance of the work for which this permit isFEE issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. .t.. Lender's Address l 1;01— ;il;I 10A 9 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 i 21 ordinances and State laws relating 'to building construction, ba and hereby authorize representatives of this County to enter TOTAL FEE c� p n the above-mentioned property for inspection purposes. V SEE REVERSE FOR EXPLANATORY LANGUAGE a ' F Signature of Permittee ate �/ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS ' d�P P UCAT I ON ._ 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 - - ADDRESS L C El Certified copy is hereby furnished. ILDING n S v�. LOCALITY A ADDRESS C _ ❑ Certified copy is filed with the county building inspectionNEAREST department. LOCALITY e /E : C ,I f CROs ST. Date Applicant- NEAREST DIS T R I C T''NO. GROUP TYPE - P CE ED BY CROSS ST: - - 6' O /� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL j L/�� y DESCRIPTION LOT'NO&;,J BLOCK MAP ^ I(IGHWAY COMPENSATION INSURANCE Mp: (CIRCLE) STATE MAI SECOND LocAI } (This section need not be completed if the work involved rQ No. of BLDGs. e p. TRACT / �� NOW ON LOT USE ZONE SPECIAL CONDITIONS ^ by the,permit is for one hundred dollars ($100) or less.) USE of U SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP // V ADDRESS q.l�'8 lc S J '(I jI/,/a� W Date Applicant 0- _LC )� 1 TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of clrY ]] / N. Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION a No Spec. Knowl. ❑ deemed revoked. Panic DOVIC@S ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION' I hereby affirm that I am licensed under provisions-of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS ❑ 9,(commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and q Q effect. I - 1\ d U PARKING SPACES REO D PROVIDED License Number Lic.Class Home Add res s - r�l �/ Q � LIMITED TIME USE Contractor Date yq/ //� DATE DATE ElPhol3eV p O✓ FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF . NO. OF 2 INSPECTOR'S acting in my professional capacity-(Section 7051, Bus- EXISTING BLDG. STORIES � SIGNATURE iness and Professions Code). ^^ ,- FINAL APPROVAL RESENT U$E OF BUILDING DFr; C L L/t� C . Lic.or Reg.No. Date- NO. /r NO. OF EXISTING BUILDINGS OppU r HOME OWNER-BUILDER DECLARATION A C C ON LOT AND USE ICE S 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 structure is not intended or offered for sale (Section 7044, Business and Professions Code). ROPOSED.USE OF BUILDING \ c- CONSTRUCTION LENDING AGENCY C l! /7 Z 2.6 1,7 A I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is # o'o o o 4 0 issued(Sec. 3097,Civ.C.). 4 Lender's Name RPROPOSED MAX. OCC. 0i0 00.0 O O Lender's Address + PERMIT FEE 1 certify that I have read this application and state that the I G+5:=80 above Information is correct. I agree to comply with all County ISSUANCE FE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon I above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ':c 10 2 -- V o Signature of Pe ittee Date WORKERS'COMPENSATION DECLARATION 76 44 (2-80) 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.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. BU LDIN 91s(� v LOCALITY • Certified copy is filed with the county building inspectionNEAREST department. L CALITY CROSS ST. Date Applicant NEAREST (\''} ( � DISTRICT NO. R UP TYPE PRO SSED BY CROSS ST. V U V - ' CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK MAP', HIGHWAY COMPENSATION INSURANCE• (CIRCLE) STATE MAJOR SECOND LOCAL d NO. OF BLOGS. (This,section need not be completed if the work involved TRACT NOW ON LOT US ZON SPECIAL CONDITIONS Q by -the permit is for one hundred dollars ($100) or less.) . USE OF SI OF LOT EXISTING BLDG. �� - ccI certify that in the performance of the work for'which this 0 permit is issued, I shall not employ any person in any'manner OWNER so as to become subject to the Workers' Compensation Laws. wtC G OCCUPANCY GROUP U .ADDRESS ' • �� `AIL ..7 (L Date Applicant 1n NOTICE TO,APPLICANT: If, after making this Certificate of Tv\; NO� 02� Q20 OCCUPANT LOAD z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICA ION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION NO Spec. KnoVVI. ❑ .deemed revoked. Panic �eVIC2S El CONTRACTORS DECLARATION OCCUPANCY INSPECTIO44 I hereby affirm that•I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS a (commencing with Section 7000) of Division 3 of the'Busi- .less 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: TO: F3I 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- E STING BLDG. STORIES SIGNATURE iness and Professions Code). PFINAL APPROVALRESENT U56 OF BUILDING y. � iJ'a6c\• Lia,or Reg.No. Date V III 9 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- D.2 6 6 2 A ness and Professions Code): NO. PARKING ) •� SPACES PROVIDED z DI, as owner of the property, will do the work and the # 0 0 0 0 8 8 structure is not intended or offered for saleSection 7044, Business and Professions Code). ( 0 0 0 0 0 o e z ROPOSED USE OF BUILDING � ' CONSTRUCTION LENDING AGENCYc O 7, 1 2-84 osI hereby affirm that there is a construction lending agency CL T�Ne 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 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 and ereby authorize representatives of this County to enter u n the above- a tioned property for inspec 'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitt a Date