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Home My Public Portal About9718 LAS TUNAS DR_Miscellaneous__ W WORKERS'COMPENSATION.DECLARATION ti 75M444 CE 875(11-84) M ISCELLANEOU ' 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 Workers'Compensation Insurance,or ' a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRBSS Certified copy is hereby furnished. ADOREss 5 4"L•�S �� LOCALITY Certified copy is filed with the county building inspectionNEAREST LOCALITY department. Ter.� Ci r CROSS ST. Date Applicant NEAREST DIST O TYPE PROCESS6 BY CROSS ST. -NST L CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIONwwY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OFLOT USE ZONE SPECIAL CONDITIONS J .• (This section need not be completed if the work involved TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less.) USE OF l; SIZE OF LOT EXISTING BLDG. l.i I certify that in the performance of the work for which this e permit is issued,I shall not employ any person in any manner OWNER, �a aMt�C L��J 6� so as to become subject to the Workers' Compensation Laws. +� OCCUPANCY.GROUP:. MAILD DR ESS, �Z� d ACQ•C''<4 — {' .' Z. PP LW NOTICE TO APPLICANT If, after making this Certificate,of •CITY Q j'1 Z(o. No� 2¢�—�Z 5 4 �''�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_ -deemed-revoked.-- -• -- • - - - 0 No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONV. I Panic Devices I hereby affirm that I am licensed under plovisions of Chapter I SAFETY PERMI (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi I NO. OF'EXITS ness and Professions Code,and my license is in full force and I effect. I PARKING REQ'D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE 1 FROM. TOO 0 I am exempt from the licensing requirements as I am a licensed architect or a registered profbssional engineer SIZE OF NO. OF I TOR"S gSjP CTURE acting in my professional capacity (Section,7051, Bus- EXISTING BLDG. STORIES iness 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 ' 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). 0 8,(18 A 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.Q. � les � O o 0 0.o.o o'o Lender's Name t z (�"p PROPOSED MAX. OCC. I a 03 8 8 r Lender's Address nn � PERMIT FEE ,O K •'f '•'• ' 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 'brdinances an Stat 1 s relating to building construction, ]hereby or' present es of this County to enter TOTAL.FEE n the a m ti ed pro y for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date