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Home My Public Portal About9209 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSAfION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 rhereby affirm that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION , or a certifi ate of Workers'Compensation Insurance,or ified copy the :of(Sec. 3800,Lab.C.). No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS ' Certified copy is hereby furnished. BUILDING ADDRESS - - LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. CONST.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. 6L0 CK MAP GHW AY NO. (CIRCLE) .$T,�A.TE MAJOR SECOND LOCAL NO. OF 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.) >_ sE of _ SIZE OF LOT EXISTING BLDG. C:)I certify that in the performance of the work for which this c3 permit is issued, I shall not employ any person in any manner OWNER I`I so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP_ "n �^ �- ADDRESS Q. T �" Date Applicant Q TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD CD Exemption, you should become subject to the Workers' "' a Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: `J r— with comply with such prOV1S10I1S OI this permit shall be deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑ `� LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 7 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 effect. PARKING SPACES READ 'PROVIDED D License Number Lic. Class LIMITED TIME SSE Contractor Date DATE D A T. ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL Lie.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 I, License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 5 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.). bo Lender's Name PROPOSED MAX. OCC. *ende�Ad*ss X P MIT FEE / I certify that I have read this application and state that the �b above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, 41 ,M and hereby authorize representatives of this County to enter TOTAL FEE ('Z.__ C__- -4 upon the above-mentioned property for inspection purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE n Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION {� CE 875 LJ 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 theaeof(Sec 3800,Lab C). Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS FICertified copy is hereby furnished BUILDING 2O f A,[ LOCALITY - ADDRESS 1�1, V 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO GROUPPE �/ , P ESSED BY CROSS ST, eX _-9 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v C'G COMPENSATION INSURANCE DESCRIPTION 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 ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which thisL o permit is issued, I shall not employ any person in any manner OWNER C-)I � so as to become subject to the Workers' Compensation Laws. MAIL N ( OCCUPANCY GROUP �� a ADDRESSrr ~ Date Applicant l� uUi NOTICE TO APPLICANT If, after making this Certificate of CITMRNoL 2 2 OCCUPANT LOAD(Z-E T 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. Know[. ❑ 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 QF t,[S` PSS effect PARKING SPACES REQ'D D PROVIDED License Number Lic. Class e ,0 LIMITED TIME USE Contractor Date DATE DATE FROM TO I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineerSIZE OF NO. OF INSPSIGEATUR' acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lic or Reg No Date HOME OWNER-BUILDER DECLARATION N4 OF EXISTING BUILDINGS (//}�(( ON LOT AND USE `� b i'Ic7 I hereby affirm that .I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- Pp_ j# j PM l-5-, ness and Professions Code). NO. PARKING 1 ❑ 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� .� O F &C*lc C1(.tb Cor11 orl'o 4-T. for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. C+° A' /0— Lender's CLender's Name PROPOSED MAX OCC. Lender's Address PERMIT FEE 5,. 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 th 1b ve-ment roperty for inspects n purposes (��'�,�� SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Permitt b Date WORKERS'COMgENSATI,ON DECL:IRATION 76nn444 MISCELLANEOUS A P P L I C A T I O N ce i hereby affirm that I have certificate of consent to self CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a rtrf'icate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab.C) Policy No Company BUILDING FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. BUILDING 901 E �U'Y .rC ADDRESS N LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST Date Applicant NEAREST D T 1CCC )S6 TYP ESS P D BY CROSS ST. / )}( CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL vU COMPENSATION INSURANCE DESCRIPTIONLOT NO. BLOCK MAP HIGHWAY rvo NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved TRACT NOWOF LDGS ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF d I certify that in the performance of the work for which this SIZE OF LOT EXISTING LDG. permit is issued, I shall not employ any person in any manner OWNER DFAADIA16 o so as to become subject to the Workers' Compensation LawsMAIL OCCUPANCY GROUP Date Applicant �� cc p ADDRESS t ,, TEL. pD NOTICE TO APPLICANT• If, after making this Certificate of CITY L NO �' OCCUPANT LOAD L I 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 plovisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION Ej No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (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 !� SPACES REq'D D PROVIDED D 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 INSPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions Code). ry�( /�.�� PRESENT USE OF BUILDING CV7 �lMi� FINAL APPROVA Lic.or Reg.No Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ^ �/ N 0 FEE 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 ElI, as owner of the property, will do the work and the SPACES PROVIDED 9969 1 AM 10o'( structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE of BUILDING C CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 5 v(zip- 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 v 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 thea ov entione property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permi a Date ,1'()KE:LRS COMPENSATION DECLARATION E 875 t1> Bal C8 MISCELLANEOUS APPLICATION Ca75 I her"eDo a cert that 1 have 1 certtftcau of consent to self COUNTY OF LOS :ANGELES BUILDING AND SAFETY DIVISION uisure, or a certificate of Workers'ComDensaUon Insurance,or a certified copy thereof(Sec 3800.Lab C 1 Pohea Vo Compam FOR APPLICANT TO FILL IN ADDRESS 111-- e' Canified copy is hereby L-urnished BUILDING �f� _ X.7 ADDRESS ZOG. U LOCALITY Certified copy is tiled with 'he county building Inspection LOCALITY CROSS ST aevartment yam: A cRoss ST Date_ __ ,pnilC int NEAREST C,STRICT NO� GRpAJP CO s=-�E4SED BY GROSS STITY RIC7/J ��,/) CO R 1 II IC\TL OF L\--MPTl0\ FROM WORKERS' LEGAL CONIPL\S±1_101+' I I'll SL'RANC_-- DESCRIPTION LOT NO IHLOCK wP HIG w�v - r/O ICIRCIct STATE NAJCR Sc CONO LOCAL' INO OF SLDGS ' I lhi� ♦e,-uon riee l no( he -omoieied if the '%Ork Involved TRACT .NOW ON LOT VSE ;ONE,SPEC.AL CONDI-1101's I the Permn is fur one nundre.: .iollars (SIOO) or less I S.Z£ OF use or i } LOT cX ISTrNG BLDG I In 'hc ^--Irrnialice , ,- -ne woo: :ur 'vnich Itis nt Is ;stiUed, 1 _ii.ul ,mt tm,to\ -m De-son in inv marine% OWNER pi ) 1 0_^e � O I - r unc ,rhre.• n 'hc ,ers Conloensanon ,aas MAIL .,�.� CCC,JP4NC ' ORCUP AOOR L= NO i IC: fO APPLi( ,NT If .v-e, naKine this C:rtlficate of CITY No` I 'CCC;;P,NT '-C—L) I , e^lotion ou snoula oe.nrie ;uDlec; to the ,1�orke:s — r rens nun °rn\ sir \ oI he L.co I-Oce '•ou rnust ,or-,h- APOLICF.TION =CP =X 17 aRCv;aR= i hro' s,.,r, )r This reri;iu ;ndU cc + — — ' TRAILER VSE %EOLOG`� INSP£'-, 'v ON � c Spec Know � i I( : \`( 1)l ('I I\1 R\L iORS DLC LAR-\710N OCCUPANC" INSPEC-ION F3nic Devices IC"Ct" 1lflrm :IId 1 -fil11Le^<_e^, 1•lae:Drovisions Of(_'l,1Dle• ( — SAP:T" PERMIT (L'S- ITEMS 9E_OW ° nnneruie '(itl, pec:'nn -0001 of Division of ;ne Susi- `- No of a ITS 7CSs ,111(1 ''"„IL•..it`7r \ +(1C :nt: T\ ,IC^."1Se is in ;II II 'Orce aru-, I Name ofJLC;=!P-.J S i P/RKING i V �I SP A CcS REC C GLO96 I LIMIT ED TiME USE nUM -O I i� .m a�:•iir turn Iiz i�ers,•le :e°uuements as I am a i I „Cnse(1 ;r,-II IIeL. .>• a -e^_!s;e-eo Drofe$sionai en2mee• I SIZE OF NC O� NSPEC-OR s aLtlne In ro% :iroie,SIVn., _er•,]LX. tSee:ion -0-11- 3us- -%('S-,N'SHLOG I STORIES S GN PE ';ies%a lid P-w,sslunq(0(1;' , - — -- RCVAL C I,r -17417 1 ' , Ili^ NO PRESENT USE Or BUILDING FINAL APD +, N. _-- i al 11O'•11 (?'•,'\i Z-lil Il.''E�Z i)C�`-Ind'-IC` � No oP EX'STING HUILolncs I ON LOT AND USC 1 Ii:*'r,•, ,Ifllnn ;hit I anI e•nDt rant the Cont:ac:o-'s I �' I ,cense I Iw .or ,hc Ioll(mina -c'sun ISe,,-ion (131 j Bus,- _ I •lei$ In(i P-OIeSSII�n,'.-Jlle' 1 NO PARKING L1 as o«ner of he DNC' ill do the wore. ano :he I SPACES PROVIDED J structure 's nu; Intenaec or offered fo/ sale (Section X041 Busmess,lnu Pruiess,unsCoae) i ( ()N51 it t'( i IO\' 1 L VDI\G '\GENC'i PROPOSED USII Or BUILDING I lie•eb, af1mn that there is a Lonstruction lemmne agency for the performance of the (Torr, for wtuch this permit is Issue(.I 1SeL 3097,Civ C 1 nde- s Name PROPOSED MAX OCC �Fi •- - I Lenity Ihdt I h.nc re.id Iles apnnL,lnon and stile that tilePERMIT FEE - 00 ahuve miurination Is Lorre,-: I.ierce to Lomviy with all County I ISSUANCE FEE orairtances and State lass relating to outiding construction, r' and hereby authorize representatives of this County to enter I TOTAL FEE 25 . 00 111)011 the shove-mentioned nroner,y for insneLtion purposes -" SEL REVERSE FOR EXPLANATORY LANGUAGE ' signature: '