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Home My Public Portal About9211 LAS TUNAS DR_Miscellaneous__ 20 WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION Of hereby affirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure, or a certificate of Workers' rs'Compensation Insurance, e,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS 1 yL5 UN S y1p I ❑ IC.II� Certified copy Is hereby furnished UILDING fAODRESS 9 oZ(� (-� TUrJ/}�j Q2 LOCALITY P�� Cir ❑ Certified copy Is filed with the county building Inspection NEAREST C department ALITY -r.�Mn� �!y„�� A Yo CROs ST /`(C/a/r1' Date Applicant EST �/// ' 7 ( r/ DISTRICT NO GROUP TYPE �PROCE SED BY qSS ST 've l A/e:74 5�8� � CONST , / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I a 1/ 141,71, COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCKMAP �� HIG.WgY rvo (CIRCLE) STATE MAJOR SECOld LOCAL d NO OF BLDGS O (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE OF //'J SIZE OF LOT EXISTING BLDG I .�� cr I certify that In the performance of the work for which this v O permit Is issued, I shall not employ any person in any mannerR JO G✓ e µ AIV so as to become subject to the Workers' Compensation Laws [PAAIL OCCUPANCY GROUP UTI WDRESS Iaf 4A,5 Date Applicant TEL Z NOTICE TO APPLICANT If, after making this Certificate of Iry 7,- If Gl 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 E] GEOLOGY INSPECTION deemed revoked 0 NO Spec. Knowl. EJ ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L1 (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. r effect SPACES REq'D PROVIDED License Number Lic Class LIMITED TIME USE J 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 SI ATURE iness and Professions Code). FINAL APPROVAL PRE NT USE OF BUILDING Lic or Reg No. Date 22i ly NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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 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) E�'FOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 21 6 9.9 A I hereby affirm that there is a construction lending agency # 9 0 for the performance of the work for which this permit Is Issued (Sec 3097,Civ C) f �1 5—$5 Lender's Name PROPOSED MAX. OCC Lender's Address PERMIT FEE I certify that 1 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, TOTAL FEE and hereby authorize representatives of this County to enter upon the above-mentioned property for mspectl n purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORnERS'COMPENSATION DECLARATION a CE 875 (11-84) MISCELLANEOUS APPLICATION CE 87f� I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,lull insured or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BAUILDING DDRESS Certified copy is hereby furnished. UILDING r ADDRESS •/ LOCALITY G 0 Certified copy is filed with the county building inspection LOCALITY __7M I �r /�/'J' �/l �/ O NEAREST (ALJ 1. ( c_a CROSS ST Date Applicant EAREST DIST}}��ICT G O TYPE / PRO ESSED BY CROSS ST. s (,�O Q^� CO T.: CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL JJ c VVV COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHw AY NOOF LDGS NO (CIRCLE) STATE MAJOR SE ND 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 OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. permit is issued, I shall not employ any person in any manner OWNER LJ �/ - y so as to become subject to the Workers' Compensation Laws. FMAIL v/� OCCUPANCY GROUP � ADDRESS //••� AVE C-3 Date Applicant 00 9L'! LL, NOTICE TO APPLICANT: If, after making this Certificate of CITY V j /�/� rTvo��/ 33/- LL Z 2, OCCUPANT LOAD N 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 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 Busi- NO. OP EXITS ness and Professions Code, and my license is in full force and effect. PARKING R6Q 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 SIZEOF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus xISTING BLDG. STORIES SIGN URE iness and Professions Code) FINAL APPROVAL 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- ness and Professions Code): NO. PARKING ElI, as owner of the property, will do the work and the s ACES 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 1 for the performance of the work for which this permit is 188 1, issued(Sec. 3097,Civ.C.) 8 8 8 E z Lender's Name PROPOSED MAX OCC O 1.22"88 '22_ Lender's Address PERMIT FEE ou 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, aniereby authorize representatives of this County to enter TOTAL FEE on the abov,- e tinned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si re of Permittee Date WORKERS'COMPENSATION DECLARATION a CE 875 (11-Sa) MISCELLANEOUS APPLICATION �7 CE 87 I hereby affirm that 1 have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab C.). Policy No CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS Certified co is hereb furnished. BUILDING f py y XX ADDRESS LOCALITY Ca 0 Certified copy is filed with the county building inspection LOCALITY ` NEAREST department. xy, �� CROSS sr. Date Applicant NEAREST DISTRICT,NO. GR P TYPE P�7aCESSED BY CROSS ST �v ,( CONST /7 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v✓ COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL NOOF SLOGS (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 SIZE OF LOT EXISTING BLDG. r I certify that in the performance of the work for which this CD permit is issued, I shall not employ any person in any mannevya OWNER of building so as to become subject to the Workers' Compensation Laws MAIL \ OCCUPANCY GROUP ADDRESSWe �, Date ApplicantIm w NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL OCCUPANT LOAD z 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 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 anis effect Name of business PARKING i SPACES REQD D PROVIDED D License Number Lic Class 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 engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code). FINAL APPROVAL -Z �s PRESENT USE OF BUILDING Lic.or Reg No Date / HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND_USE V °I✓✓✓ I Hereby affirm that I am exempt from the Contractor's Q� License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO. PARKING ❑ 1, 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 s PROPOSED MAX. OCC. _ Lender's Address PERMIT FEE25 . 00 ^'I I certify that I have read this application and state that the above infor tion is correct I agree to comply with all County ISSUANCE FEE h- orduranc nd State ws relating to building construction, and her a ize r esentatives of this County to enter TOTAL FEE 25 . 00 '7 Upon t bo men ed property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE XX _ _% Sign: e Date