The URL can be used to link to this page

Home My Public Portal About9738 LAS TUNAS DR_Miscellaneous__ 1, I 4ORKERS'COMPENSATION DECLARATION 875(2-80) CE MISCELLANEOUS APPLICATION CE 875 } I hereby:-affirm that I have a certificate of consent to self insure, orla certificate o:workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified c�opy thereof(Sec.3800,Lab.C.) ' Policy Nol/ CompanyAp-T Q/tlAlp/A/L��r/, PPICNADDRESS FOR APPLICANT TO FILL IN Certified copy is hereby furnished. uILDING ADDRESS 1 LOCALITY �❑ Certified copy is filed with the county building inspection 97 '40 S uj.�AS 1712 SEs I . NEAREST department. LOCLITY T-emn1p. City CROSS ST. Date Applicant11IR EST DIST�(CT NO. GROUP PE IPPqRSSED BY CROSS ST. GoldDIST CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL t COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP h HIGHWAY N O.0_0 (CIRCLE) STATE MAJOR SECOND LOCAL 0.NO. OF BLDGS. (This section need not be completed.if the work involved, TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS i U by the peimit is for one hundred. dollars ($100) or less.) USE of SIZELOT EXISTING BLDG. " 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, WNER ��/�� U so as to become subject to the Workers' Compensation Laws. i d�� n OCCUPANCY GROUP lL Date Applicant t. ADDRESS Q lt��CT �� , 4 U) NOTICE TO APPLICANT: If, after making this Certificate of f clry /L t, Q/�oL 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 , deemed revoked. TRAILER USE GEOLOGY INSPECTION NO Spec. KnOWI. ❑ ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 Busi- NO. OF EXITS ness and Professions Code, and my license is in full force.and r PARKING. effect. REO'D E== PROVIDED SPACES License Number Lic.Class ! LIMITED TIME USE Contractor Date ` DATE DATE ❑ FRO:M: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer y SIZE OF NO. OF I INSPECTOR'S acting in my professional capacity (Section 7051, Bus- I EXISTING LD G. STORIES GNATURE 190717-7 iness and Professions Code). SEFINAL APPROVAL NT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXIST( G 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): iNO.PARKING (SPACES PROVIDED ❑ I, as owner of th'e property, will do the work and the ! 2 LJ Ii,O A structure is not intended or offered for sale (Section 7044, Business and Professions Code). I ROI # 0 0 0 0 8 8 POSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 'o 0 0 0 0 0 o z I hereby affirm that there is a construction lending agency 1 661 M1 46bo(f _ for the performance of the work for which this permit is I 0 627-85 issued(Sec.3097,Civ.C.). Lender's Name I PROPOSED MAX. OCC. ; Lender's Address P'SRMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County I'SUANCE FEE o dinances and State laws relating to building construction, TOTAL FEE nd hereby authorize representatives of thi County to enter I pon the above-mentioned property for I pection purposes. S}Ik.E REVERSE" FOR EXPLANATORY LANGUAGE 1 ture of Permittee Date yl,. ` V 0I I WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELL=ANEOUS APPLICATION I CE 875 L� I hereby affirm that I have certificate of consent to self I COUNTY OF LOS ANGELES I BUILDING AND SAFETY DIVISION I'L.Itt 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 ADDRESS Certified copy is hereby furnished. Vo I015UILDING ! :? LOCALITY l� i ❑ 1 ADDRESS J Certified copy is filed with the county building inspection n NEAREST depattment. YCROSS ALITY yy� rJ/(� CROSS ST. Date Applicant REST �— (DISTRICT CRO P TYPE PRO ED BY ST. j' C -ONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY ?- No. �� (eIRCLE) STATE MAJOR SECOND LOCAL O NO. OF BLDGS. (This section need not be completed if the Work involved TRACT NOW ON LOT USE Z NE S DIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) I USE OF SIZE OF LOT EXISTING BLDG. IX 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 ,,) so as to become subject to the Workers' Compensation Laws. I AIL OCCUPANCY GROUP LV ! AO DRESS �J Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of I CITYA OCCUPANT LOAD Exemption, you should become subject to the Workers' i 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. ❑ C] No Spec. Knowl. OCCUPANCY INSPECTION Panic Devices E LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) I 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 1 Neffect. PARKING. I SPACES REQ'D ==7PROVIDED O License Number Lic.Class LIMITED TIME USE 'Contractor Date DATE DATE I am exempt from the licensing requirements as I am m I 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 iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING '1'-+�'/—,I• I Lic.or.Reg.No. Date i I. 0 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUIL (NGS , ON LOT AND USE , 1 , I hereby affirm that- I am exempt from the Contractor's I o (d License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): j NO.PARKING o SPACES PROVID EO ❑ I, as owner of the property, will do the work and the 1 v D o D D a'a structure is not intended or offered for sale (Section I i 7044, Business and Professions Code). P POSED USE OF BUILDING p 8 1 4-811. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency I (fr')) 7— vim.-LP. for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name I PROPOSED MAX. OC-Cfj 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 FEES f Grdinan s and State laws relating to building construction, I TOTAL FEE and he by authorize represe Ives of this County to enter up 9n e a above- SEE rope ty inspe 'on pure ses. I SEE REVERSE FOR EXPLANATORY LANGUAGE lgn •f a of Permittee ' Date I . I WORKERS'COivIPENSATION DECLARATION CE 875 (71-84) MISCELLANEOUS APPLICATION ^ CE 875 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 I i a certified copy thereof(Sec.3800,Lab.Q. P !1 i Policy No. Company I FOR APPLICANT TO FILL IN BUILDING f�� DDR ESS Certified copy is hereby furnished. BUILDING LOCALITY IADDRESS ag 1 e Certified copy is filed with the county building inspection r LOCALITY NEAREST department. Temple City CROSSST. i Date Applicant NEAREST ) UISTR IC;NO. GRO IjP TYPE P ESSED BY i CROSS ST. L 'Jill ��//!� CONST. 1 CERTIFICATE OF EXEMPTION FROM WORKERS" LEGAL !/ L� I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIC Hw AT STATE MAJOR SECOND LOCAL NP. NO. OF BLDGS. CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT UISE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) usE of 1 ' SIZE OF LOT I EXISTING BLDG. I certify that in the performance of the work for which this ,) C _ f permit is issued, I shall not employ any person in any manner. OWNER AK so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP I I Date Applicant ADDRESSZ. TEL. ! • NOTICE TO APPLICANT: If, after making this Certificate of clrY C No. 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION r; No Spec. Knowl. e deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT LIST ITEMS BELOW) ' ) I 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 SPACES REO'D PROVIDED 1 License Number Lic. Class 0 LIMITED TIME USE LL y Contractor Date DATE GATE U) F I am exempt from the licensing requirements as I am a FROM: TO: m i licensed architect or a registered processional engineer. SIZE OF No.of INSPECTOR'S z i acting in my professional capacity (Section 1051, Bus- EXISTING BLDG. STORIES SIG NATUR m inessandProfessionsCode). FINAL APPROVAL O PRESENT USE OF BUILDING J�'•-/(5�9� U Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS ON LOT AND USE (l �i�Ln,CQI$ I hereby affirm that I am exempt from the Contractor's v w License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING Vyh I, as owner of the property, will do the work and the• SPACES PROVIDED structure is not intended or offered for sale (Section' j I 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY 'K PROPOSED USE OF BUILDING Al L Al bRtl I hereby affirm that there is a construction lending agency j for the performance of the work for which this permit is, issued(Sec.3097,Civ.Q. Lender's Name I PROPOSED MAX. OCC. Lender's Address ! I PERMIT FEE 25.00 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, ; apd hereby authorize representatives of this County to enter TOTAL FEE 25.00 rty for inspection purposes. I upon the above-mentioned pro eSEE REVERSE FOR EXPLANATORY LANGUAGE Signat of Permittee Date i l