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Home My Public Portal About9167, 9167 1/2 LAS TUNAS DR_Miscellaneous__ 1VORKERS'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 copy thereof(Sec. 3800,Lab.C) 01 Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS I Certified copy is hereby furnished. BUILDING �� LOCALITY ��v l ADDRESS ElCertified copy is filed with the county building inspection LIDD. T NEAREST department Ernpt, C 1 CROSS ST. Date Applicant EAREST �OI 1J� DISTRICT OU TY E PROCESSED BY CROSS ST. 1 (� �-I , NST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v COMPENSATION INSURANCE DESCRIPTION I LOT No BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECON LOCAL NO OF BLD 63. (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 S ZE OF LOT EXISTING BLDG. :I— I certify that in the performance of the work for which thisT C permit is issued, I shall not employ any person in any manner OWNER �L (y1A so as to become subject to the Workers' Compensation Laws AILOCCUPANCY,GROUP o A DRESS167 465 ~ Date Applicant - w NOTICE TO APPLICANT• If, after making this Certificate of m Y �o� Cf; ITvoL ® 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 ❑ GE OGY INSPECTION E] No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION occuawry cY INSPECTION I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERM ❑ (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� effect. PARKING REQ'D D PROVIDED 1 SPACES J License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE PROM TO I am exempt from the licensing requirements as I am a INSPECTOR architect or a registered Professional engineer SIZE OF NO. OF acting in my professional capacity (Section 7051, Bus- E TING BLDG STORIES SIGNATURE mess and Professions Code) 11 FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS p I �7 ON LOT AND USE :2S 51; / A I hereby affirm that I am exempt from the Contractor's # 0 0 0 9 8 8 License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO. PARKING •,e o e o,• • z F1I, as owner of the property, will do the work and the SPACES PROVIDED I 6 8 7 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 for the performance of the work for which this permit is `0 issued(Sec. 3097,Civ C.). Lender's Name \(�� PROPOSED MAX OCC Lender's Address PERMIT FEE IYU 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 ordinance State laws relating LA building construction, an her�Ka'l au orize representatry f this my to enter TOTAL FEE u nthZvA-mntloned property sp on purposes EE REVERSE FOR EXPLANATORY LANGUAGE gnature of m Date WORKERS;COMPENSATION DECLARATION 75M444 M I SC E L LA N EO ''S P L I C A T I O N CE 875 (11-84) I hereby ;affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES RIJILDING AND SAFETY DIVISION msure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) " Policy No Company FOR APPLICANT TO FILL IN ABUILOI DDRDR �� i ADESS (v ❑ Certified copy is hereby furnishedUILDING '1114-7 TA ,f LOCALITY ADDRESS FICertified copy is filed with the county building inspection LOCALITY �/ A 9 NEAREST department. OV I! `,(r(v CROSS ST Date Applicant NEAREST r a DISTR��SSTT NO G UP TYPE P ESSED BY t511—i CGt� 4 CONST CROSS ST. !/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO (cIRCLe) STATE MAJOR SECOND LOCAL NOOF 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 SIZE OF LOT EXISTING BLDG.OF 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 OWNERS.')so as to become subject to the Worker ' Compensation Laws. MAIL S OCCUPANCY GROUP a o AD DR ES � tJdVe i Date Applicant w NOTIC T APPLICANT If, after making this Certificate of CITY �/ m a` 0 ► NDL 4-13 OCCUPANT LOAD 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 ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 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 �.� i/�Q effect A"0 PARKING SPACES REq'D D PROVIDED License Number Lie. Class s LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a PROM' TO licensed architect or a registered professional engineerSIZE OF NO. OP INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES g F ATURE mess and Professions Code) FINAL APPROVAL ,Q PRESENT USE OR BUILDING Lic or Reg.No Date _ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS c i J �_N I* ON LOT AND USE '// ' I hereby affirm that I am exempt from the Contractor's ^ ' —I! 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). 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 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 authorize representatives of this County to enter TOTAL FEE �O upon the ab e mentioned property for inspection purposes � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dai e WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION 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` ADDR SS / 7 y ADDRESSVIZ, / /6 Certified copy is hereby furnished BUILDING l/� �� DLDIN LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY'I��w I t NEAREST department. 11 _l r CROSS ST. Date Applicant NEAREST DISTRICT NO GROUP TYPE P ESSED BY CROSS ST. ` /D� -] CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ip( COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NOOF LDGS NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOW. ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE SIZE OF LOT EXISTING BLDG.of �C 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 OWNER W y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP la��] o ADDRESS CQsTu S Date Applicant LU TEL ��/ �/� CIL- NOTICE �I,t1 - NOTICE TO APPLICANT: If, after making this Certificate of CITY Ct No /VY/�w OCCUPANT LOAD C/, Exemption, you should become subject to the Workers' Z 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 ❑ 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 Busr SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force and ` effect. `e 7 I PARKING REQ'D pROVID ED ' a� SPACES License Number Lrc. 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 INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code). FINAL APPROVAL 6— //_1 Lic.or Reg.No Date RESENT USE OF BUILDING I l� '71 HOME OWNER-BUILDER DECLARATION NO, of EXISTING BUILDINGS ', ON LOT AND USE - ' I hereby affirm that I am exempt from the Contractor's �1 L- t/ _ License Law for the following reason (Section 7031.5, Busi- Ip 41' 0000—`001 I/.ill/9y ness and Professions Code): NO. PARKING }'U�i 1 F�M1'�C _ El1, 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 pR OPOSED USE of BUILDING Rn TIA+ 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 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 ISSUANCFr FEE - ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL,FEE upon the above-mentioned property f r inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) 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. ADORES SS 6� p LOCALITY ADDR ,W ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO I GROUP TYPE PROCESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL 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 slzE of LOT EXISTING BLDG. r O permit is issued, I shall not employ any person in any manner OWNER v U so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDR ES9�L O _ Date Applicant T L.7 NOTICE TO APPLICANT If, after making this Certificate of CITY94- \ No� 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. deemed revoked. � Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION q) 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 "Ai D� ` �o effect IN1�l PARKING REQ'D PROVIDED � SPACES License Number Lic. Class 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 OF NO. OF NSPE CTOR acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S.GNATU mess and Professions Code). b FINAL APPROVAL G rA 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- 00i}>_'( - 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency J 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 au horize re .resentativ4 of this County to enter TOTAL FEE upon the ab ent n property or inspection purposes � O SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pen ittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION -� . • CE 875 I r ur ,o affirm that 1 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 ADDRESS 9 4— ❑ Certified copy is hereby furnished. ' ADDRESS �� tAG) LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. -k1:N 0 CROSS ST Date Applicant NEAREST I DISTR IC'[NO U TYPE P CESS BY CROSS ST. /Vc'� — CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR .OND OCAL NO OF LOGS. (This section need not be completed if the work involved TRACT NOW ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE SIZE OF LOT EXISTING BLDG.OF 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 OWNER VIF e)ukvkI, =' so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP a ADDRES V Date Applicant I,.J TEL NOTICE TO APPLICANT• If, after making this Certificate of CITY NO. g — — 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 E] GEOLOGY INSPECTION E] No Spec. Know]. El deemed revoked. Panic Devices 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 Busi- SAFETY PERMIT (LIST ITEMS BELOW) NO OF EXITS ness and Professions Code, and my license is in full force and 1'T7 effect. VW�'� PARKING SPACES REQ'D PROVIDED License Number Lic. Class r LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No. of FROM T.- , pEcroR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES s NATUR mess and Professions Code) FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE 6'9 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 E SPACES PROVIDED 0 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDIN / I 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. 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 a thorize representatives of this County to enter TOTAL FEE on the abme do pr ed ope `y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 qn- Signature of rmittee Date