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Home My Public Portal About9815 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSgTION DECLARATION CE 875(2-80) ��i�I ®l�Y APPLICATION I hereby 'affirm that I have a certificate of consent to self S insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF ]LOS ANGEL.Ff %/�. BUILDING AND SAFETY DIVISION a certified copy thereof(Sec.3800,Lab.C.) L/ Policy No. Company FOR APPLICANT TO FILL IN BUILDING Q 1 ADDRESS Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS .ti —y�_,- G Ceitified copy is filed with the county building inspection NEAREST department. •• LOCALITY CROSS ST. Date Applicant NEAREST, DIST CT Ny GROUP TYPE PROCESSED BY CROSS ST. �V CONST. LEGAL CERTIFICATE OF EXEMPTION FROM WORKERS' } DESCRIP 1 N LOT NO. BLOCK pr� COMPENSATION INSURANCE NOP (fa��e�Ej STATE MAJOR SECOND LOCAL d NO. OF BLOGS. O (This SBCtIOn need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT 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 OWNER U so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W ADDRESS Date' Applicant r—p� NOTICE TO APPLICANT: If, after making this Certificate of CITY NoL ��..i 0 OCCUPANT LOAD z Exemption, you should become. subject to the Workers' PLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such pIOvisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. NO Spec. Knowl. ❑ Panic DeVIC@S ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTio I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi01 EJ - ness and Professions Code, and my license is in full force and effect. I + SPAC ESG: REQ'D E_� PROVIDED D License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: yTb: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer slzE OF NO. OF INSPECTOR'S acting in my professional Capacity (Section 7051, Bus- EXISTING BLDG. STORIES !� SIGNATURE '• iness and Professions Code). PRESENT USE OF BUILDING 1 FINAL APPROVAL119 Lic.or Reg.No. Date V HOME OWNER-BUILDER DECLARATION NO.OF AN19 UNG•BUILDINGS ON LOT AND USE hereby affirm that- I am exempt from the Contractor's cense Law for the following reason (Section 7031.5, Busi- ' sS and Professions Code): NO.PARKING SPACES PROVIDED I, as owner of the property, will do the work and the �'S 21.5.p structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED SE OF BUILDING \o 0 0'0'2 CONSTRUCTION LENDING AGENCY 2 s,o 6 0 0 ; reby affirm that there is a construction lending agency 4 he performance of the work' for which this permit is• •e o o`61 i.0 0'x i (Sec.3097,Civ.C.). is Nameq �} PROPOSED MAX. OCC. 0 .51 1 —81" 1" r'sAddress PERMIT FEE ify that I have read this application and state that the ��••// c,o information is correct.I agree to comply with all County ISSUANCE FEE antes and State laws relating to building construction, TFEE BO ere y uthoriOTALze representatives of this County to enter 1 bov oned op for 'nspection purposes. StE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee Date ' WbRK> 1SFt COMPENSATION DECLARATION CE 875 MISCELLANEOUS A P P L I C A°TIO N �� ' r� I' CE 875(11-84) I herebyraffert ,hat I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION inslsre, or a•-certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANTTO FILL IN BUILDING ADDRESS 1S Certified copy is hereby furnished. uILD ING A 5 � (� LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY .�/ (//�� NEAREST department. dL_ 6, CROSS ST. Date Applicant NEAREST DISTRICT N(�O. G OUP TYPE PR S¢ED BY CROSS ST. �1� `%,v OU CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Vo L COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP AY STATE MAJOR SECO D LOCAL NO.NO. OF SLOGS. (CIRC O. (CIRC (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. I . }' 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 owN ,bLl�e � so as to become subject to the Workers' Compensation Laws. MAIL Gr OCCUPANCY GROUP [E�] o ADDRESSL ~ Date Applicant TE NOTICE TO APPLICANT: If, after making this Certificate of CITY t.bb(Gi Noi l — 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION i 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 effect. , SPACESG REq'D = FROVIDED D License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE 0 1 am exempt from the licensing requirements as I am a FROM: 01 licensed architect or a registered professional engineerSIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXI TING BLDG. STORIES SI ATURE iness and Professions Code). PR FINAL APPROVAL E3ENT USE OF BUILDING � G (�'� Lie.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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING t • � l ,(n A 5 2 6,8 A I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is # 0 0 0 0 $$ issued(Sec. 3097,Civ.C.). 1 \\rh o o D D o o 0 Lender's Name 1 PROPOSED MAX. OCC. O a Lender's Address R 18 I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction � and hereby authorize repre tatives of this County t ent TOTAL FEE upon the ab en �eperty for inspectio pure ses �� r/ SEE REVERSE FOR EXPLANATORY LANGUAGE ,/ /Signature of Permittee �J ate I (.6 WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICA eI®N I hereby affirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company I FOR APPLICANT TO FILL IN❑ BUILDING f�ADDRESS Certified copy is hereby furnished. BUILDING 7�� 7��+ T1t�I ]� ADDRESS 9815 LAS .LIJLVAS DFL LOCALITY J Certified copy is filed with the county building inspection00 TEMPLE CITY CA. 91780 NEAREST department. LOCALITY I CROSS ST. Date Applicant NEAREST DIS TRI GROUP TYP PROC SED BY GROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COInM HI COMPENSATION INSURANCE'P TRACT DNOWESCRIPTION LOT NO. -73BLOCK MAP � (C GHWA RC E) STATE MAJOR SECOND LOCAL a �t NO. (This section need not be com completed if the work involved 4f(OSol eX 55f- NO. OON LOT F BL T USE ZONE ECTAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) US F? OF V SIZE OF LOT EXISTING BLDG. ��/ Ir 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 P r STM U so as to become subject to the Workers' Compensation Laws. � OCCUPANCY GROUP 0 AMAIL AMDDRESS 300 E. 11%G(��]�A VISTA [W-2 fL Date Applicant In NOTICE TO APPLICANT: If, after making this Certificate of CITY RCADIA, CA. 91Q ' 447-0025 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 deemed revoked. ❑ ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 1#—C?— Panic Devices I vreby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS S (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and elfeCt• SPACES ' REO'D D PROVIDED O Y License Number Lic.Class 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 OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES slGNdru ,5. mess and Professions Code). ESEFINAL APPROVAL NT USE OF BUILDING 7 Lic.or Reg.No. Date NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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 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). ROPOSED USE OF BUILDING 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 I certify that I e a tl is application and state that the above informs o is Jrr ct.I agree to comply with all County ISSUANCE FEE ordinances a tat Is s elating to building construction, TOTAL FEE and hereby tl orir. r r of this County to enter �upon the a v -me io ed o rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date