HomeMy Public PortalAbout9219 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
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 Wor(ters'Compensation Insurance,or "fl
a certified copy thereof(Sec 3800, Lab C.)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished BuILDiNG n LOCALITY
ADDRESS
❑ Certified copy is filed with the county building Inspection NEAREST
department LOCALITY fn /cj Cil (,I Pt���i0 CROSS ST.
Date Applicant ARF�ST l ` ) DISTRICT NO GROUPTIP
PR SSED BY
CROSS ST - CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL r
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP cIIRCLEY }
( ) STATE MAJOR SECOND LOCAL a
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q
by the permit is for' one hundred dollars ($100) or less.) U
USE
of
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 anamanner OWNS
so as to become subject to the Workers' Compensation,Laws AIL n T OCCUPANCY GROUP W
60 ADDRESS 9 a' 4L / •/`•l.1 t- 41665 Q-'
Date Applicant ^ Z
NOTICE TO APPLICANT If, after making this Certificate of IrYT NOL 8 8 d� "� � OCCUPANT LOAD
Exemption, you should become subject to the Workers' AP KATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply With such provisions or 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 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 � y�� 4 WCC PARKING.
effect SPACES REO'D O PROVIDED O
License Number Lie Class yly
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 SIGNATURE
mess and Professions Code).
ESENT USE FINAL APPROVAL OF BUILDING
Lie.or Reg No Date �/ ��SYYIGGVI/
Utb mcchqoic,
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AN D'USE
I hereby affirm that I am exempt from the Contractor's 9 8 S 6 A
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code)- NO.PARKING # •'• 9'o8'8
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) 0 3,2 1 8 Q
ROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Rk QC 7777L
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,
and hereby authorize representatives of this County to enter TOTAL FEE
"Wed
pon he above-mentioned property for inspectio purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Qke �F�° -
vt'" 7 n i�/'� Date
i \\nR1:LRS ('014PENSAFION DCCLUR.\TION 76M444 MISCELLANEOUS APPLICATION
C6 875 (1 1 84)
'Thereby 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 thereof(Sec. 3800, Lab C 1
Pol[c% NoC -AUDI IL �S
D NSG
., ompany yo1�9 -
Certified ool a FOR APPLICANT TO FILL IN hereby furnished BUILDING S uoAUTY
ADDREss
I Certified coov is-ilea with the count, building inspection LOCALITEAR EST
department CROSS ST
Date Apohcant NEAREST DISTRICT NO Z, ITYPE: ESSEDPBY
CROSS 5T p CONST-�� I�
CERTiFIC ATE OF EXEMPTION FROM \\OR1:EP.S' LEGAL e / e
LOMPE\S-\TION li\S[.R\`.CE OESCRIP-'ON LOT VO BLOCK 5717E MAJOR SECOND LOCAL
moo• Ic,RCLc)
NO OF 111-OG-9 section need nn[ he ompleted if the work n%olved -RAC- NO.
ON LOT USE _ONE SPECIAL CONDITIONS
b% the permit Is for one hundred dollus ISMO) or lets ) use OF
311E OF -OT EXISTING aLOG
! _eatfs ?hat in ne De'•wmanLc )t •!:e •,ars -e: '�luca -his
permit is issued, i :hail not emviot um De:-,on n am• tr.anne: OWNER -
so as to oecome �uniec• -o :he ''\o*kers Comcensanen Lads "A AILW J ` OCC::PaNCY GROUP -
A
�
Date \OrhLant — DDRESS a N
=,Iel
_ _-
\OTICL r0 %P°L!C\\T If .user mak.re 111s .erutLite )[ X c,T- 5 /(f Cl E OCC'.1P4N7 LOAD
E,emotton, Lou >noulo become sublec; -o -he \\ r ers �a _
Comoensanon mrmisiens n :he Laoor COae ' ou -nits[ ror h- P e LICA71ON FOR U EXi7 HARC'VVARE
,nth comnl. 1 r_'t ^_-mne
tswils nr ail ^ - -
_'SE — GEOLOGY INSPE_ oec- O•J N10 SK lovil '
- _Omcd re'or.�u - L�-J--�
LICENSED I ONTR.,CTORS JELL \R \,U ', JCCJPANC' INSPEC-ION B Panic Devices l i
1 ne Oos at.'trm at I,= licensed under arovistensof Chao,c -1
Q SAFETY PERMIT — (LIST ITEMS 3E LO tvI
- ILommencme 'Lith Sectlen 0001 of Dt.[von 3 0t -lie Bust- No OF ExI-s ISI
less Ana Prrtc�siens Code and ms lire-ise 's :n till orce ind
.'.•IeL: �iPKING 'I
SPACES REO O D avJVID ED I I
_ L,ccase \umle- _ L.L C'as.
LIMITED TIME USE
^ .int aLt)r D
C•Tc o• _
nI :nn 21 2-Ic: :r h: iL:sire :ecuce:ne-ii,
— hLc sed art`uieL 0 O^IstO ci �rntes,tun,l _ _' J_ --Z OF INSPEC-OR 5
:n '1', 071'J,C,�101.11 Se---n: _ !)t'C -X'S- NG 3L=t: -TCR'ES I SIGNATURE
Iness ana P-otession�l.JtleI
_ E ,- JSE O� UILOING FINAL A? ROVAL
Z$— /p
Lr ,Ir J. ___ - -- Il-
E tNI119
rn
0 'S\\ CR-3LILDCR DEQL\R ''„iU`. No JF EXISTING 9UILOING$ Q'
- -o- SND 1-ISE
v
t' '1 as
f ',erect atrni -Ila[ I Inn :%emo, -nm Con[:1-.or ,,
LILense L i•< <0, -,he ,liu”m,a Olson 'Sv, [or I _ 3uu- t�t
ness Ind D'oiessions l"oue) vo PARKIUG
SPA C__S .ROV IO ED
1, IN ,, 0: of "he Ornoer, ,ill do •he %crn -n-, !•e
structure is iut mended or o[te:cu o, ai_ Sez-ion
Bu,Iness mu PrOtessions C)de) r
A �ROPOSEO 'JSE OF BUILDING
CONSTRlFT1O\ I_L\DI\G \GC\I-1
I heren, atfum that :here is .1 Ltnistruction lendm2
for the performance of the work tut MnLii tats Der-nit is
issued (Sec 300- Cit C i
Lends ,\Ince ----------_----
PROPOSED MAX OCC
L.mder, \duress
( i1 „gritty that I hale rad ;his apDltcauon Ana state "ha? ;he PERMIT FEE 25.00'
aoo\enformotion is correct 112ree to Lompis '.sith all CounTV ISSUANCE FEE
ordmancces and State lass rel'I
tine to bu[lulns conslruL,ion
[nd herebv authorize representatives of this Counts to enter TOTAL FEE 25.00
upon the above-mentioned prorern for inspe%tion Purpoxs
" I SEE RLQ ERSE FOR EXPLANATORY LANGUACE
R x