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HomeMy Public PortalAbout9822 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a CE 875(2-80) MISCELLANEOUS 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 C:) - Policy No. Company FOR APPLICANT TO FILL IN BUDDING ADDRESS ❑ Certified copy is hereby furnished. BUILDING LOCALITY ADDRSSS ' ❑ Certified copy Is filed with the county building Inspection _ NEAREST ' department LOCALITY �O (i` CROSS ST Date Applicant NEAREST /'l DISTR CT NO GR P TYPE - PR SOD BY CROSS ST. Q•QVI cA--'P\ ti .CONST -CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY No.- (CIRCLE) STATE MAJOR SECOND LOCAL EL NO. OF SLOGS. :EL (`1'hlS SCCtIOn 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.) U USE OF �q SIZE OF LOT EXISTING BLDG I certify that in the performance of the;work for which this, I l /— per`nilt is issued, I shall not employ any person in any manner OWNER 'tG so as'to,become subject to the.Workers' Compensation-Laws MAIL OCCUPANCY GROUP ADDRESS 8Z2 %its W Date Applicant iZ8?"Oy N NOTICE TO APPLICANT If, after making this Certificate of No. .2 OCCUPANT LOAD 2 Exemption, you should become sutilect to the Workers' Compensation provisions of the Labor Code, you must forth-, APPL ATION FOR EXIT HARDWARE with comply with'such provisions "or this permit shall be TRAILER USE GEOLOGY INSPECTION ' ❑ ❑ No Spec. KnoWl ❑ .deemed revoked. _, - - ❑ • LICENSED CONTRACTORS DECLARATION occurwrvcY'irISPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter- (commencing hapter SAFETY PERMIT' (LIST ITEMS BELOW) NO OF E. ITS «) (commencing with Section 7000) of Division 3-of the Busi- Cess and Professions Code, and my license Is in full force and ' effect PARKING REO'D PROVIDED .� -• SPACES 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 OF NO. OF INSPECTOR'S acting in my'professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE inessand Professions Code).; FINAL APPROVAL �q PRESENT USE OF BUILDING � 03 Lic.or Reg.No Date rJ HOME OWNER-BUILDER°DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE , I hereby affirm that I am exempt from the Contractor's x'6,5 4.5 A License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING SPACES PROVIDED• aI, as owner;of the property, will do the work and the # o,o e;0 8 8 structure Is not intended or"offered for sale (Section o o,o 0 0 0 0 7044, Business and Professions Code) _ PROPOSED USE OF BUILDING - 8 2 CONSTRUCTION LENDING AGENCY Ic I hereb'y 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 OPOSED Max OCC Lender's Address PERMIT FEE - - 1 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 I ordinances and State laws relating to building construction, TOTAL FEE G/!!fi ' G and hereby authorize r presentativ s of•this County to enter, up bove-m ntI ed prope y for inspection purposes' SEE REVERSE FOR EXPLANATOfr5LANGUAGE S ture of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) 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'cert>ficate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800;Lab C). Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING rj{�� ADDRESS Certified copy is hereby fu niched. BUILDING ADDRESS IJy I��•IC Q2Z �S 7'!//VftS Z CJ LOCALITY ElCertified copy is filed wit the county building inspection LOCALITY Te� / - /)d 9/ /O NEAREST department. CROSS ST Date Applicant NEAREST DISTRICT NO I G OUP TYPE PR CESSED BY CROSS ST ' F O _� CONST. / CERTIFICATE OF EXE PTION FROM WORKERS' LEGAL vd COMPENSA ON INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO OF BLDGS NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not b completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for o e hundred dollars ($100) or less.) USEOF TI SIZE OF LOT EXISTING BLDG. BI � I certify that in the pe ormance of the work for which thisrj� o permit is issued, I shall of employ any person in any manner OWNER nS =� so as to become subje to the Workers"Compensation Laws. o MAIL I ��RL >r� �^/ OCCUPANCY GROUP �- Date plicant ADDRES VVV _� t NOTICE TO APPLI ANT: If, after making this Certificate of CITY VVVVVVVV©VV���� EG TEL U� OCCUPANT LOAD Exemption, you s ould become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation pro stuns of the Labor Code, you must forth- with comply wit such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. Eldeemed revoked. Panic Devices LICENS CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm hat I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEMS BELOW NO OF EXITS ness and Profe stuns Code,and my license is in full force and �p effect. n iv D n PARKING SPACES REQ'D PROVIDE D _ License Nu er Lie. Class J SQAJ CSU ,e0 3 �-A• —/v�'_,• LIMITED TIME USE Contractor Date DATE FqE!F 0 I am exempt from the licensing requirements as I am a i FROM TO lice ed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acts g in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES _ SIGNAJURE -� me sandProfessionsCode) G OCe FINAL APPROVAL PRESENT USE OF BUILDING Lie.or eg 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 0 I, as owner of the property, will do the work and the SPACES PROVIDED X structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING /7 B 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 Lender's Name ��, PROPOSED MAX OCC. Lender's Addie PERMIT FEE �- � I certify thatr I av read this application and state that the above info ati Si i corre I agree to comply w5 -all County ISSUANCE FEE ordmancesand St to s relating to b constr ctio and hereby:au o iz ep se tat this Co n t ent r TOTAL, FEE u on the above a Lone pr rty for in ,u p se r SEE REVERSE FOR EXPLANATORY LANGUAGE Sidn ure of ermrtt Da e i WORKERS' COMPhNJAiIUNL)tl,LAKAIIUIN 20-0063DPWt2/90 Irli=�%.•G.L.L,HINr_%-;U 5 Hr-r—L.IL.HI IIJIN I hereby affirm that I have a certificate of consent to self COUNTY OF L0�"ANGELES BUILDING AND SAFETY DIVISION •-insure, or a certificateof Workers' Compensation Insurance, or a certified copthereof , 380,,0..,J.A C/)'� � O Policy No o any X`t Ar�,rY�rY1`, FOR APPLICANT TO FILL IN BUILDING - BUILDING ADDRESS }� ADDRESS j ❑ Certified copy is hereby furnished g 22 S r. LOCALITY ❑ Certified copy is filed with the county building Inspection CITY - ZIP department. � . NEAREST CROSS ST Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' consr. a- COMPENSATION INSURANCE TRACT ( BLOCK LOT NO MAP HIGHWAY No (CIRCLE) _ STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BOOKPAGE PARCEL IN: by the permit is for one hundred dollars ($100) or less.) �'Z r USE ZONE SPECIAL CONDITIONS 0 I certify that in the performance of the work for which this s IIrT!g a TEL NO permit is issued. I shall not employ any person in any manner42J7 a so as to become subject to the Workers' Compensation Laws. A DRES -w Q- OCCUPANCY GROUP Date Applicant CITY �� ziP^ NOTICE TO APPLICANT If, after making this Certificate `''[, 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 F-1 , revoked. R -❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I Panic Devices I r: I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) C' 9(commencing with Section 7000)of Division 3 of the Business Name o usiness l ` I OF EXITS and Professions Code,and my license is in full force and etfecc ;15 PARKING REQ'D PROVIDED � License Number Lic Class S , hSPACES I Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am a DATE DATE licensed architect or a registered professional engineer FROM To acting In my professional Cap8Clty (Section 7051,Business SIZE OF NO OF INSPECTOR'S I EXISTING BLDG STORIES 1 SIGNATURE, and Professions Code) Lic Or Reg NO - Date — PRESENT USE OF BUILDING FINAL APPROVAL 1 HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS I ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License P Law for the following reason (Section 70315, Business and- Professions Code)- NO PARKING I ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Y PROPOSED USE OF BUILDING Business and Professions Code). `� k 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) PROPOSED MAX OCC Lender's Name _ uc T r T) n nA TE No Lender's Address AbDRE4S I certify that I have read this application and state that the above information is correct I agree to comply with all County 1 PERMIT FEE , I ordinances and State laws relating to building construction,and - • - , , hereby authorize representatives of this County to enter upon ISSUANCE FEE i a I the above-mentioned property for inspection purposes TOTAL FEE Xl' �'2-lT6 SEE REVERSE FOR EXPLANATORY LANGUAGE I( natu-ire of enmttee Date