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Home My Public Portal About9212, 9212 1/2 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) WS' E L LA N EO U S APPLICATION I I.ereby airirm 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 BUILDING C ADDRESS {J Certified copy is hereby furnished UILDING LOCALITY 11 F-1CertifiedCertified copy is filed with the county building Inspection NEAREST department OCALITY �.' J CROSS ST. Date Applicant NEAREST DISTRIC NO GROUP TYPE PROCESSED BY CROSS ST v O -� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ��jJJJ! (J a } COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP (CIRCLE) LE) STATE MAJOR SECOND LOCAL d NO (CIRCLE) (This section need not be completed if the work involved NO OF BLDGS. USE ZONE SPECIAL CONDITIONS 0 P TRACT NOW ON LOT (, by the permit is for one hundred dollars ($100) or less.) USE OF � �J cr SIZE OF LOT - EXISTING BLDG. �l 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 v OWNER / so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP W _ I ADDRESS 1 -2 a Date Applicant '/ Q q Z NOTICE TO APPLICANT If, after making this Certificate of CIT��✓6,0 ttj 'SI No� l0 1 3 3 OCCUPANT LOAD Exemption, you should become subject to the Workers' 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 0 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 i (LIST ITEMS BELOW) NO. OF EXITS a 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 REQ'D 11�� PROVIDED I 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 ND OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIG ATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL 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 I-�= License Law for the following reason (Section 7031 5, Busi- L/ ness and Professions Code). NO. PARKING q SPACES PROVIDED El1, as owner of the property, will do the work and the 1 structure is not Intended or offered for sale (Section 7044, Business and Professions Code) PROPOSED USE OF BUILDING , CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ei�l�QJ for the performance of the work for which this permit is 101 issued(Sec. 3097,Civ C) Lender's Name PROPOSED MAX OCC. Lender's Address PERMIT FEE BO 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, TOTAL FEE �BG and hereby authorize representatives of this County to enter upon the above-mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ��igna2 y z Sture of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I heigby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 2in lure;or a certificate of Workers'Compensation Insurance,or 3 ertlfled copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING A C J ADDRESS ❑ Certified copy is hereby furnished BUILDING1 r OCALITY ADDRESS 4` G ❑ Certified copy Is filed with the county building inspection NEAREST department - LOCALITY C✓ .CROSS ST Date-,Applicant NEAREST /�+ DISTRIC NO G O TYPE PROCES D BY CROSS ST `/�, ` �1 CONSS/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY NO no (CIRCLE) STATE MAJOR SEGO D LOCAL d 6 (This SOCtIOn need not be completed if the work involved TRACT NOWOF BLD5.ON LOT USE ZONE I SP O CIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG cr I certify that in the performance of the work for which this �� QO permit is issued, I shall not employ any person in any manner OWNER U IVA so as to become subject to the Workers' Compensation Laws. MAIL Gy �� OCCUPANCY GROUP UJ ADDRESS a Date Applicant to NOTICE TO APPLICANT If, after making this Certificate of CITY ( � NOLd OCCUPANT LOAD Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE. with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION C] ❑ 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 q (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 REQ'D O PROVIDED O License Number Llc 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 SI NATURE mess and Professions Code) _ L/- PRESENT USE OF BUILDING FINAL APPROVAL G i `�� 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 2 6 25 A License Law for the following reason (Section 7031 5, Busi- # • • • • 88 ness and Professions Code) NO PARKING El1, PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section O S 0 8_8 5 7044, Business and Professions Code) PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 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 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 State laws relating to building construction, TOTAL FEE 1. and hereby authorize representatives of this County enter 11 upon t above-menti ed prop ty for Inspec ' n p rpos s. E REVERSE FOR EXPLANATORY LANGUAGE Signa r S Permittee D j4 e I N�ORKERS'CO)[PEiiSAIION DECLARATION CE 875 (11-84) M ISCELLANEOUS APPLICATION I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION " insure, or a certificate of Workers'Compensation Insurance,or 1a—F7, a certified copy thereof(See.3800,Lab C) ` + PP �'J Policy No Company FOR APPLICANT TO FILL IN BUILDING .aD DR ESS FlCertified copy is hereby furnished. X BUILDING vn t? �' ��C yyi /�� Dn ` IocA LITY ADDRESS (L J"�IAAV ftGT I I a Certified copy is filed with the county building inspection X LOCALITY {✓� //�' NEAREST department. ' IPL✓ y CROSS ST. Date Applicant NEAREST DISTRICT NO GROUP TYPE P ESSED BY CROSS ST, �D /5_ CONST 1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL moo/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK HIGHWAY vo. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed If the work Involved TRACT NOW ON LOT LZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF l SIZE OF LOT EXISTING BLDG. /'� I certify that in the performance of the work for which this VVVVVV _ permit is issued, I shall not employ any person in any manner X OWNER OJEZ �Qf✓V so as to become subject to the �Vorkers' Compensation Laws g ✓I �//��I�� A �ij� OCCUPANCY GROUP A DRESSqW ✓ �/{.Y.�aY IGL{r1-Ido � Date applicantEi-I �/� 4 — NOTICE TO APPLICANT If, after making this Certificate of g CITY 67�VVf— ,c NO �rp� ��q OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code you must forth- i with comply with sucli pIo%isions or this permit shall be TRAILER USE IJ GEOLOGY INSPECTION I— No Spec. Knowl. deemed re%cked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION LX Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LiST I EMS BELOW) 1 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 R.W. D PROVIDED D SPACES oLicense Number Lic Class LIMITED TIME USE N Contractor Date DATE DATE 1- -O [ am exempt from 'he licensing requirements as I am a 9 i licensed architect or a re^__istered protessional engineer Size OF uO OF INSPECTOR'S Z acting in t pro[e,sional CapaLM ISeCIIOn 031. 31,S- ZXISTING SLOG STORIES SIGNATURE in w� mess and Professions Code) c FINAL APPROVAL LIC or Ree No Date V_ PRESENT USE OF BUILDING /� 2 I 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 follo%%ing reason (SeLtion 7031 5, Busi- ness and Professions Code) NO PARKING El1, as owner of ,lie property, will do the work and the SPACES -ROVIDED structure is not intended or offered for sale (Section 7044 Business and Protessiuns Code) n � CONSTRLCTION LENDING AGE\C'' g PROPOSED USE OF BUILDING 12. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 4� o issued(Sec. 3097,Civ C I E . ,—I (tet Lender's Name 4 PROPOSED MAX OCC. I Lender's Address 25.00 r__ I certifv that I hale read this application and state that the PERMIT FEE I— t+ Ppy above information is correct I agree to comply w ith all Coanty ISSUANCE FEE ordinances and State laws relating to building construction, f and hereby authorize representatives of this County to Enter TOTAL FEE 25.00 TI •� upon the above-m ioned propert) for inspection purposes. ` X � � g ^n �- SEE REVERSE FOR EXPLANATORY LANGUAGE On (A _11 n t.l SiRnatu e of n. ,Intoe Date C:I ',.i