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Home My Public Portal About9214-9216 LAS TUNAS DR_Miscellaneous__ V90RKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS A PP L ItAT IO N inhereby affirm that I have 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 thereo�(Sec 3800, Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING / ADDRESS R—J J Certified copy Is hereby furnished ILDING -T ff LOCALITY ADDRESS ` //•J 2 � V `2 f MCertified copy is filed with the county building Inspection NEAREST ` department OCALITY ; CROSSST JEA1 61 M/ _ Date Applicant AREST DISTRICT N GR UP TYPE ` PRO SED BY ROSS ST. CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL — v COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND OCAL d section need not be completed lthe work involved by t by the permit is for one hundred dollars ($100) or less.) TRACT NO OF BLDGS.NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 USE Ir SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this 0 permit Is Issued, I shall not employ any person in any manner WNER F— so as to become subject to the Workers' Compensation LawsAIL OCCUPANCY GROUP W ADDRESS �/ /C tZ Date Applicant n y U) NOTICE TO APPLICANT If, after making this Certificate of Y NOL LSO �' �C OCCUPANT LOAD z IT 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 GEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION JQ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY-PERMIT ❑ (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 D License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE OFROM TO I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF 0 •I:SP 'gyp R's # acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES }F SI 'AT mess and Professions Code). RESENT USE OF BUILDING I FINAL APPROVAL _7y LIc or Reg.No Date !� HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE 0 2 2 2=8 5 1 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 El1, 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) ROPOSED USE OF UILDING 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 1 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 Count to enter TOTAL FEE upon the ab o -mentio r erty for inspectlo purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of PerqiIttee�— to W(1Kf:LRS'C06IPI.NSA7ION 1)ICIARAIION /cnnnnn CE 875 t t i snl MISCELLANEOUS APPLICATION i _ I lied by affirm that I have a LertdlLate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFL'FY DIVISION a certified copy thereof(Sec. 3800, Lab C) Policy No Company BUILDING FOR APPLICANT TO FILL IN ADDRESS 9a/� Certified copy is hereby furnished BUILDING /y� ` ADDRESS / 6A,5 'J v D ((ldr LOCALITY Certified copy is filed with the county budding inspection LOCALITY NEARF ST department CROS_ ST Date Applicant NEAREST DISTRI T NO GR P TY PE�� E .SED BY CROSS ST /401, G CY.P. y CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0 N// _. COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY NO OF BLDGS. NO (CIRCLE) STATS MAJOR SrzLt ND LOCAL (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 I certify that in the performance of the work for whichthis SIZE OF LOT EXISTING BLDG. permit is issued, I shall not employ any person in any manner OWNER �ft,,Givsd> e-_5 so as to become subject to the Workers' Compensation Laws MAIL `.' //�, 7 OCCUPANCY GROUP ADDRESS 1365 �• e(.rJ " / IZI Date Applicant NOTICE TO APPLICANT- If, after making this Certificate of CITY/ OjmA TEL NOTICE 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 of this permit Shall be TRAILER USEGEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS ness and Professions Code, and my license is in full force and /////J effect C E'. PARKING REQ'D PROVIDED ACEI, License Number Lie Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as 1 .un a F'RO M TO hcensed architect or a registered professional engineer SIZE OF ND OF INSPECTO S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES 51;,NATYOIRE iness and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING _[ Lrc.or Reg No. Date HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS g I hereby affirm ON LOT AND USE 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, 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). CONSI'RUCIION LLNDING AGENCY I,PHOPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is I issued (Sec 3097,Civ C.) I_41 Lender's Name _ PROPOSED MAX OCC r Lender's Address G I 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, Ad hereby authorize representatives of thisCounty to enter TOTAL, FEE upon the above-mentioned property for inspection purposes sl 1' Rf VI,R1;F I-OR EXPLANATORY LANGUAGE Signature of Permittee Date F^ i