HomeMy Public PortalAbout9176 LAS TUNAS DR_Miscellaneous__ WORKERS (OMPENSAIION DECLARATION Lm"I MISCELLANEOUS APPLICATION
i 20-0o6111DPw 12'SU I
1 hereby affirm that I have a Lelnl lLale 01 Lonsent t l ,e IJ COON-FY OF LOS ANGR CS BUILDING AND SAFETY DIVISION
Insure,or a Lertil lcate of Worker, (onnpul,,ttion InMud(.C, or
a certified cop) thherreool (Sec 3800 Lab C ) I.
Policy Nu oin pa IIy p.�e �� FOR APPLICANT TO FILL IN BUILDING
BUILDING ADDRESS ADDRESS
❑ Certified copy Is hereby lulnlshed \-� LOCALITY j
❑ CertllLed copy 1s I Iled with the count) building insprLlum CITY ZIP
J departmentT \ 4T NEAREST
ems• e C. C g�Z ll CROSS ST
Date _ Applicant SIZE OF LOT Z NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY
CERTII ICAII-.OF LXLMP1ION I-ROM WORK Ri 00
CONST 1
1 COMPLNSATION INSURANCE TRACT BI_ocK LOT NO —1 HIGHWAY �-
j ,T No ICIRCLEI STATE MAJOR SECOND LOCAL
1 (THIS secllon need not be C0I111PIC(Cd If Illc "'OIL 111\01%Cd ASSESSOR MAP BOOK PAGE PARCEL
by the perll is for one hundred dollar% (s10O1 111 testi.) USE ZONE SPECIAL CONDITIONS
lll
1 gently that In the perlotmancc til (ILL look for which this OWNER TEL NO -
- ! I
permit Is Issued. I shall not employ nn) person ul any m,nuni
so as to become ,ubJeLt to the Workers Contpen,mion Laws ADDRESS OCCUPANCY GROUP rr•
Date Apr''—1.11 CITY ZIP �
NOTICE TO APPLI"AiJT If allel making this (ert�l,Late OCCUPANT LOAD
of Exemption, you should become subject to the Workers APPLICATION FOR
Compensation provisions of the Labor Code you must I0r•hwlth EXIT HARDWARE
comply with such provisions or this permit ,hall be d-enied TRAILER USE❑ GEOLOGY INSPECTION L1
_t i revoked � No Spec Knowl E]LICENSED CONTRACTORS DL( t AR VFION OCCUPANCY INSPECTIONiLII Panic Devices ❑
1 hereby affirm that I am licensed Under plovi,1ons of ( iapter SAFETY PERMIT❑ ILIST ITEMS BELOW I
- 1 I 9(commencing with Section 70(0)of DI\ision 7 of the Bu,mess NO OF EXITS El
\/ and Professions Code and my license Is In full IorLe and effect
WNW GF U*tk:.I r.S5 PARKING
- i REQ'D D PROVIDED D
z License Number 6�✓08q� l tc ('Liss \V1 SPACES
t � /.
Contlactol tri" 0,) CoA Dalc k\ lo\ U LIMITED TIME USE
i v
DATE DATE
El I am exempt from t le licensing reyunenients I, I .Iln I FROM TO
licensed architect or a registered professional c nruteer
acting in mv
) plotcsunal capacuti
) (tieLan 7051 Bu,nlc SIZE OF NO OF
„ Z ---�
^tel and Plolc,,sio ns (ride) EXISTING BLDG (� f� STORIES INSPECTOR S
__ SIGNATURE
L1c or Reg No Date
PRESENT USE OF BUILDING FINAL APPROVAL oOZ d
r IIOML OWNI-R-61,111-DLR IN ( I AR AI ION NO OF EXISTING BUILDINkS
I ON LOT AND USE
1 hereby all lrn that I ,Inn ewinpl nom the('011110001', 1 ILCII,L' -
Law for the following le.lson (SCL(lon 70115 Busing•, and
Professions Code) NO PARKING
ElSPACES PROVIDED
L d5 owner LII the propellt IL 111 dII lite IIIuk soul IIiL' - ------
StlElctElle I, 1101 intended of 011CICd 101 ,,IIC 00010i1 7044, PROPOSED USE OF BUILDING
I Business and Professions Code) -
~1 I CONSTRUCTION LENDING AGENCY ce V5�
I hereby alflrnt that there I, a con,nuctlon lending ageiiL� fol
the performance of the Hoik for "Inch thl, permit I, Issued
,�
(Sec 3097Civ C )�) PROPOSED MAX OCC
Lender's Name ___ - -__ - _ _ _ APPLICANT(P&INT) T L NO -
I X --5�"e
Lender's AddressADDRESS
I certify that I have read this application and state that the
i above Information Is correLt I agree to comply with all County PERMIT FEE
ordinances and State laws relating to building constructlun and
hereby authorize representatlles of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes
TOTAL FEE
' `�'-o � ( SEF REVERSE FOR EXPLANATORY LANGUAGE
�
Signature of Pernntee Date
r
y I