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Home My Public Portal About9819 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self CE 875 (2-80) COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING If p DDRE55 Certified copy is hereby furnished. BuD 1LING LdCgLITY AODR'ESS Certified copy is filed with the county building inspection NEAREST ' department. LOC E- CROSS ST. lee Date Applicant NEAREST DISTRICT N6. GROUP" TYPE PROC SSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved NO. OF LOT USE ZONE SP CIAL CONDITIONS CL P TRACT NOW ON LOT O by the permit is for one hundred dollars ($100) or less.) U SIZE OF LOT EISTING BLDG. USEXOF I certify that in the performance of the work for which this cc permit is issued, I shall not employ any person in any manner O so as to become subject to the Workers' Compensation Laws. MAIL �r OCCUPANCY GROUP U ADDRESS J OW. Date Applicant N NOTICE TO APPLICANT: If, after making this Certificate of CITY f o. 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 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 Q (LIST ITEMS BELOW) NO. OF EXITS 9 commencing with Section 7000)of Division 3 of the Busi- ne s and Professions Code, and my license is in full force and PARKING: effect. SPACES REq'D PROVIDED License Number Lic.class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a, licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES - SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date C HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE J 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 ` D r El 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). PROPOSED 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.). mender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that 1 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, TOTAL FEE and hereby authorize representativ s of this County to enter upon the bove-mentio propert for ' specdon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per tte Date , WORKERS'COMPENSATION DECLARATION E 875((11-84) MISCELLANEOUS APPLICATION I hereby a cert that I have a certificate of consent tself 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 FOR APPLICANT TO FILL IN BUILDING ADDRESS L�►��' Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT N T TYPE P CESS BY CROSS ST. ►�+,O CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NO. OF BLDGS. NO. H cllw AY STATE MAJO SE CO D LOCAL (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 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 C3 permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL PANCY GROUP o Date Applicant ADDRESS �- 1)4U5_. W NOTICE TO APPLICANT: If, after making this Certificate of CIT NEL. _ OCCUPANT LOAD Exemption, you should become subject to the Workers' (CATION 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❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PER r ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Bu 1- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. AMOaMiNiVessPARKINGREq'D PROVIDED 11 SPACES License Number Lie. Class - / LIMITED TIME USE Contractor Date =D19 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 NSPE CTOR s g p I sI Nwru E acting in my professional capacity (Section 7051, Bus- Exisrl G BLDG. STORIES t iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVA Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 6' ILE EE ON LOT ANI I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness usi 0000-0001gfO ness and Professions Code): NO. PARKING .y El I, as owner of the property, will do the work and the SPACES PROVIDED 91433 1 AN 9:53 structure is not intended or offered for sale (Section 7044,Business and Professions Code). 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. Lender's Name O PROPOSED MAX. OCC. Lender's Address PERMIT FEE l� 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 re a ntativ s of this County to enter TOTAL FEE n the above-mentio roperty or inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitte to WORKERS'COMPENSATION DECLARATION CE 87501-84) M I SC E L LA N EO U S APPLICATION I lure, o.affirm,'that I have a certificate of consent to c 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 US ��Certified copy is hereby furnished. wooREss❑ Certified copy is filed with the county building inspection LOCALITYdepartment.Date Applicant NEAREST GROUP TYPE ' PR ESSED BY CROSS ST. � CONST. /�'CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALCOMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF HLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of I certify thatin the performance of the work for which this SIZE OF Lor EXISTING BLDG. O permit is issued,I shall not employ any person in any manner OWNER ; i ��N i'll C � =' so as to become subject to the Workers' Compensation Laws. MAIL r /�. qi OCCUPANCY GROUP a o Date Applicant ADDRESS �'( 9 L, Q v NOTICE TO APPLICANT: If, after making this Certificate of CITY T--e, ,?Q,,• N.. 4—*1-P`)-10 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. 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 �/I}/, effect. , ` �'v—^ y e (k46Q,0,1PARKING SPACES REQ'D D PROVIDED O License Number Lic. Class 144 t&I LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer- SIZE OF NO. OF FROM: To: INSPECTOR'S acting in my professional capacity (Section 7051, Blas- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL. / �3—� Lic.or Reg.No. Date RESENT USE OF BUILDING �0 7 O F 1—21 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS I ON LOT AND USE I hereby affirm that I am exempt from the Contractor's �/ (! [i}J [I— tf1,J i /1oI . License Law for the following reason (Section 7031.5, Busi- U' 1� ness and Professions Code): NO. PARKING "1' [,} I, as owner of the property, will do the work and the SPACES PROVIDED LiC715 Ptd 1:e 41 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agen J' for. the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. 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 i OmnnF�� for in ection purposes. cd SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Date