The URL can be used to link to this page

Home My Public Portal About9171 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8454(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 capy thereof(Sec 3800,Lab.Q. Policy No Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS 2171 GS Certified copy is hereby furnished. ooREss 7 L /✓�s / LOCALITY El departmecopy is filed with the county building inspection LOCALITY 7�� e�-7- cRoss sr. -I Cr Date Applicant EAREST �/ J�(� a DI TRICT,I�1O ROUP TYPE PRO E ED BY CROSS ST. �( [,G CONSTCERTIFICATE OF EXEMPTION FROM WORKERS' o ' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP RNO ICRwARLE) STATE MAJOR SECOND LOCAL (GIC NOOF BLDGS. (This section need not be completed if the work involved TRACT NO.W ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF IZE OF LOT EXISTING BLDG. 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 mariner WNER so as to become subject to the Workers' Compensation Laws. AIL k:OCCUP,ANCY.CiROUP:._4 Date Applicant DDR-47/ IV/901f/ k157' TEL' OCCUPANT LOAD NOTICE TO APPLICANT• If, after making this Certificate of CITY �� No. --® c�i, 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 E] GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revokedIC Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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- A NO. OF EXITS ness and Professions Code,and my license is in full force and effect W1►�'/ PARKING REQ'D PROVIDED SPACES 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 INSPECTOR'S' acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SP NATURE: inessand Professions Code). `'` FINAL APPROVAL PROF BUILDING !// Lic or Reg.No. Date ESENT USE HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS FEE 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 =-W01 b/ 8/89 DI, as owner of the property, will do the work and the SPACES PROVIDED 3M 1 PM 4`W. 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.Q. Lender's Name PROPOSED MAX OCC. Lender's Address ,00 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 J-' 49 up thea ve-me toned pr ope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I Signature o rmittee Date f W4 *1 ERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affim 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 BUILDINGADDRESS ❑ Certified copy is hereby furnished BUILDING '/ A� LOCALITYZ. ADDRESS / ?' Certified copy Is filed with the county building InspectionNEAREST t department J, LOCALITY /! f�- CROSS ST Date Applicant AREST G T DISTRIC(0 GR P TYPE PR SSED BY CROSS ST N C�� / G�} U CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL IC COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MOP HIGHWAY STATE MAJOR SECON OCAL d NO (CIRCLE) O , (This section need not be completed if the Work involved NO OF BLDGS USE ZONE SPECIAL CONDITIONS P TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less.) U USE OF SIZE OF LOT EXISTING BLDG I certify that m the performance of the work for which this 0 permit is Issued, I shall not employ any person in any manner WNER j `so as to become subject to the Workers' Compensation Laws AIL �D� OCCUPANCY GROUP W $00 oNT ADDRESS yLi�S �� ,S �e o N Date Applicant Z NOTICE TO APPLICANT If, after making this Certificate of ITY �/� NOL - OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLI ATION FOR EXIT HARDWARE With comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION NO Spec. Knowl. ❑ deemed revoked. - � - Panic D2VICeS ❑ - LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 1 (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 PARKING. effect SPACES REO'D O PROVIDED D License Number Lic Class LIMITED TIME USE , Contractor Date DATE. DATE FROM TO F1 I am exempt from the licensing requirements as I am a INSPECTOR'S licensed architect or a registered professional engineer SIZE OF NO. OF acting in my professional capacity (Section 7051, BUS- EXISTING BLDG _ STORIES IGNATURE mess and Professions Code) 0C TX r I FINAL APPROVAL la—_5— Lic RESENT USE OF BUILDING or Reg No Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 2 0 8 Q 3 A ON LOT AND USE I hereby affirm that I am exempt from the Contractor's # • • • • 88 License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING • • • • • • ,• 8 SPACES PROVIDED ❑ I, as owner of the property, will do the work and the I a 15`�8 4 structure is not Intended or offered for sale (Section 7044, Business and Professions Code) ROPOSE D'U SE OF BUILDING �5i3O CIONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is i 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 St;§& uilding construction, TOTAL FEE and he by authothis County to enter upo ;4: inspec Ion urpo s SEE REVERSE FOR EXPLANATORY LANGUAGE ,�0 - Signature of Permittee Date