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Home My Public Portal About9676 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE e76(11-84) MISCELLANEOUS APPLICATION I llereliyra cert that I have a certificate of consent to c sg1£ COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance;or i a certifiad copy thereof(Sec.3800,Lab.C.). Policy 1Vo. Company FOR APPLICANT TO FILL IN BUILDING 7� - ADDRESS Certified copy is hereby furnished. BUILDING / o LOCALITY ADDRESS �-�'�d Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST / DISTRICT NO.'I G OUP i TYPE PSR ESSED BY CROSS ST. /V d� -^ CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT OF S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) UsE OF SIZE OF LOT EXISTING BLDG. d 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 OWNER g� a&1101/yO1�i;::] s) so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS Date Applicant i W.J TEL' NOTICE TO APPLICANT: If, after making this Certificate of CITY OCCUPANT LOAD LY NO. Z Exemption, you should become subject to the Workers' gppL CATION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code,you must forth ❑ with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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. G / PARKING REQ'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 PROM? O. licensed architect or a registered professional engineer. slzE of NO. OF INSPECTOR'S g P !p acting in my professional capacity (Section 7051, Bus-, EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). PRESENT USE OF BUILDINGX D INAL APPROVAL / Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 0R Q FE ON LOT AND USE �� i l .140 I hereby affirm that I am exempt from the Contractor's 7 License Law for the following reason (Section 7031.5, Busi- �� ✓/1Lv Qt7��_0001• 12/ 1/92 ness and Professions Code): NO. PARKING ;f SPACES PROVIDED ., ❑ I, as owner of the property, will do the work and the 6768 1 PM 5:06 structure is not intended or offered for sale (Section •7044,Business and Professions Code). ' CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGX 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 I certify that I have read this application and state that the PERMIT•FEE C96—1(/ 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 as;QQ upon the above-mentioned property for inspection purposes. yy SEE REVERSE FOR EXPLANATORY LANGUAGE —q� Signature of Permittee Date {' I WORKERS'COMPILN84ULUN vinCLAKAHUN " 2D-DD63DPIN,2190 M15C:t,LLANEt7U_S APPLICATION L hereby affirm that I have a certificate bf consent to'self COUNTY OF LOS'--ANGELES BUILDING AND SAFETY DIVISION •.:.Ttnsure,or a certifidate of. Wdrkers'Compensation Insurance,or _. � I ,acertified copy thereof(Seir:3800, Lab.C.)� ' Policy•No Company FOR APPLICANT TO FILL IN BUILDING 1Bi, LDING ADDRE S ADDRESS ' I ❑ Certified copy.is hereby:furnished. LOCALITY ❑ Certified copy is filed'with the county building inspection CITY ZIP/ idepartment CROSS ST. ' Date Applicant SIZE OF L011 NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY O CERTIFICATE OF EXEMPTION FROM WORKERS' i CONST. t TRACT BLOCK LAT NO. (" I COMPENSATION INSURANCE MAP N HWAY LNO. ICIRCLEIIRCLEI STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL ; USE ZONESPECIAL CONDITIONS C by the permit is for one hundred dollars ($100) or less.) ri � y a TEL NO. + I.certify that in the performance.of the work for which this l LL I permit is issued.'e I shall not employ any person in any manner I so as to become subject to the Workers' Compensation Laws. noDREssa U� -r- OCCUPANCY GROUP cr i P,Lai( ) Date Applicant . CITYZIP NOTICE TO APPLICANT: If; after making this Certificate _{ O OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the.lAbor Code.you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ NO Spec.Knowl. ❑ t revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[I f 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 Business game dt liustuess NO.OF EXITS and Professions Code.and my license is in full force and effect. PARKING• REWDD PROVIDED D License Number Lic. Class _ P i SPACES ( I I Contractor Dateyowi-LYL ' J .n H/b � LIMITED TIME USE El FROM:I am exempt from the licensing requirements as I am a TO: DATE DATE licensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business SIZE NO. INSPECTOR'S and Professions Code). EXISTINNG BLDG. STORRIES SIGNATURE. Lic or Reg No. Date PRESENT USE OF BUILDING FINAL APPROVAL p� 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, Business and ( ' I Professions Code): NO.PARKING SPACES PROVIDED i ❑ I. as owner of the property, will do the work and the i structure is not intended or offered for sale(Section 7044,1 PROPOSED USE OF BUILDING Business and Professions Code). _ { � I I CONSTRUCTION LENDING AGENCY iI 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'.). PROPOSED MAX.OCC Lender's Name APPLICANT(PRIM) TEL NO. Lender's Address ADDRESS 3 ( j I certify that I have read this application and state that the above information is correct I agree to comply with all County PERMIT FEE F, I ordinances and State laws Yelating to building construction,and - % hereby authorize representatives.of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. I ra •' _ TOTAL FEE . c. !' $ SEE REVERSE FOR EXPLANATORY LANGUAGE- f Signature of Permittee Date i