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Home My Public Portal About9177 LAS TUNAS DR_Miscellaneous__ WOIEKERS'COMPENSATION DECLARATION It CE 875 (11-84) MISCELLANEOUS APPLICATION J� CE 875 � I I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IILJII insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab C.). BUILDING Policy No Company FOR APPLICANT TO FI LL IN ADDRESS C Certified copy is hereby furnished. aooRess 9f� u U LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST Date Applicant NEAREST DISTRICT NO. Jeg?rC�� TYPE P CESSED BCROSS ST. O CONST. I / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a �/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL NO OF 13 LD (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 LDG. > 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 �� Lig I ® C-3 so as to become subject to the Workers' Compensation Laws C / / OCCUPANCY GROUP � O MAIL Date ADDRESS Applicant `✓( LUQ NOTICE TO APPLICANT If, after making this Certificate of CITY G 07t NOL< OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI ATION 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. OCCUPANCY INSPECTION E] Panic Devices LICENSED CONTRACTORS DECLARATION 1 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 Busr NO. OF EXITS ness and Professions Code, and my license is in full force andVim// bus r/i effect iJ�t /e PARKING SPACES REO'D PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date , DATE OAT E FROM TO• I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineerSIZE OF NO of INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 51 TORE 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 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•' '—r' �r.' i �;� 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). 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 issded(Sec 3097,Civ C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE C31L� 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 upon the b ve-mentioned property for inspection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE O L Signa/ re of Permittee D to WORKERS'COMPENSATION DECLARATION CE 875 Y__ MISCELLANEOUS A P P L I C A T I O N CE 875 (11-84) I herebaffirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec 3800,Lab. C) Policy No. Company FOR APPLICANT TO FILL IN ABUILDING DDRESS 9i7 �/�� G�ygS FICertified co is hereby furnished. BUILDING�[- y/ PY Y ADDRESS r I 1 �r LOCALITY 14/1-5 c c_/ 0 Certified copy is filed with the county building inspection LOCALITY NEAREST /� department CROSS ST Date Applicant NEAREST DISTRICT NO. GROUP ITYPE PROCESSED BY CROSS ST. n CONSV CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �( �/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NOOF LDGS NO (CIRCLE) STATE/`1 OR SECOND LOCAL . B (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. d 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 fY _ so as to become subject to the Workers' Compensatio Laws. ADORES MAIL OCCUPANCY GROUP Q U Date Applicant C-3 NOTICE TO APPLICANT: If, after mak TE`' making this C ificate of CIT NoOCCUPANT LOAD o_ c . Exemption, you should become subject to t e Workers' APPLICATION FOR EXIT HARDWARE _ Compensation provisions of the Labor Code, yo must forth- with comply with such provisions or this p rmit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Kno deemed revoked. LICENSED CONTRACTORS DECLA ATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under pro isions of Chapter 9 (commencing with Section 7000) of Divi on 3 Of the Busr SAFETY PERMIT LIST ITEMS BELOW NO. OF EXIT ness and Professions Code, and my license s in full force and C'11�/�J 0 effect. U V14�� PARKING SPACES REO'D PROVIDED License Number Lic Cla s IMITED TIME USE Contractor Date 57 // DA DATE ❑ I am exempt from the licensing r quirements as I am a FROM TO licensed architect or a registere professional engineer SIZE OF NO OF INSPECTOR'S acting in my professional capac y (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code). FINAL APPROVAL F15 �2—�j PRESENT USE OF BUILDING`/ / Lic.or Reg No. Date L HOME OWNER-BUILDER ECLARATION NO. OF EXISTING BUILDINGS 43 FEE ON LOT AND USE I hereby affirm that I am exem t from the Contractor's License Law for the following rea n (Section 7031 5, Busi- Hit ness and Professions Code) NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED p P Y> O 1fi i+ a structure is not intended o offered for sale (Section , 7044,Business and Profession Code). CONSTRUCTION LEN ING AGENCY PROPOSED USE OF BUILDING` G' I hereby affirm that there is a construction lending agency n 1 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 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 andtate laws relating to building construction, and hereby auth rite representatives of this County to enter TOTAL. FEE upon the above- entioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perm to