HomeMy Public PortalAbout9155 LAS TUNAS DR_Miscellaneous__ WORK;�RS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION {�
CE 875 IJ
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 cop theyggof(Sec. 3800 Lab.Q.
Policy No. 104�T�ompany St,COmp. Iris. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
FICertified copy is hereby furnished. BILDING
ADUDRESS 9155 Las Tunas Drive LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY NEAREST
department. - cRoss ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE P O ESSED BY
CROSS ST. Enc n'ta & Loma gQ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �U �J�.
COMPENSATION INSURANCE DESCRIPTION I 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 ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) use OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued, I shall not employ any person in any manner ow o
0�i�rles Katherine Denise Fastlaben &
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
AMAIL DDRESS Gloria Krajnik _ o
Date Applicant Same LUJ
NOTICE TO APPLICANT: If, after makingthis Certificate of CITY TEL. rn OCCUPANT LOAD 0-
Exemption, 818-285-6800 _
Exemption, you should become subject , 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'USEGEOLOGY INSPECTION ❑
❑ ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices E
I hereby affirm that I am licensed under provisions of Chapter SAFETY PER IT ETV (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 REQ•D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineerSIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. I STORIES SIG,NATURE
iness and Professions Code).
' PRESENT USE OF BUILDING Office for FINAL APPROVAL '
Lic.or Reg.No. Date [1z z
Loose Leaf Tilina 'Service '
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 • 10F IEEE
I, as owner of the property, will do the work and the 'PACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
PROPOSED USE OF BUILDING Office (same)
CONSTRUCTION LENDING AGENCY ,;;
-
I hereby affirm that there is a construction lending agencyi '1
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name ACU.r.r._
PROPOSED MAX. OCC. _
Lender's Address E 4tq: I EEE
PERMIT FEE
1 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, y5r``y
and hereby authorize representatives of this County to enter TOTAL FEE
on the e- n 'oned ropert spection purp ses
I ' ( SEE REVERSE FOR EXPLANATORY LANGUAGE t x�-'1 AN 8'01
Signature ermittee Date D �3�I�I U '