The URL can be used to link to this page

Home My Public Portal About9901 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS A P P L IC AT IO N 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 tertifled copy thereof(Sec 3800,Lab-C.) Policy No Company FOR APPLICANT TO FILL IN BUILDING , - ADDRESS ❑ Certified copy Is hereby furnished JU iLDING LOCALITY1 - DDRESSQ901 Certified copy Is filed with the county building InspectionNEARESTdepartment OCALITY J�7. cRoss ST ,Date----.- Applicant EAREST ! _ DISTRICT NO. 'GR P TYPE PROC ED BY CROSS ST CONST - CERTIFIC-ATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY } NO (CIRCLE) STATE MAJOR SEC D LOCAL Q. N O..OF BLDGS (This,section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or-less.) . - - USE OF SIZE OF LOT EXISTING BLDG - cc I certify that in the performance of the work for'which this Q permit Is Issued, I shall not employ any-person In any.mannerOWNER U" so as to become subject to the Workers' Compensation Laws 1AiL OCCUPANCY GROUP ?� W • ADDRESS - A / /De-' Date-Applicant NOTICE TO APPLICANT" If, after making,this Certificate of CITY, P� rriEL 6. OCCUPANT LOAD Z Exemption, you should become subject ,to the Workers' APPLICA ION 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, occuPAMCY•INSPECTION❑ Panic Devices ❑ I hereby•a61rm that I am licensed under provisions of Chapter SAFETY PERMIT Q• (LIST ITEMSBELOW) 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 PARKING. effect. SPACES REO'D PROVIDED License Number Lic Class LIMITED TIME' USE Contractor'• Date DATE DATE ❑ V - _ FROM TO a ' I-am exempt from the licensing requirements as I am licensed architect or• a registered professional engineer SIZE OF NO. OF INS CTO R'S acting In' my.professional capacity (Sectlon,7051, Bus- ' ISTING BLDG STORIES SI NATURE mess and Professions Code). - P �A� FINAL APPROVAL - , RESENT USE OF BUILDING ��• Lic or Reg.No Date HOME OWNER-BUILDER DECLARATION NO of EXISTING BUILDINGS' - - ON LOT AND USE I hereby affirm that 1 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 -985.2.9 A structure,Is not Intended or offered for,sale (Section 7044, Business and Professions Code)- PROPOSED USE OF BUILDING X11,�Q t7�+Q^ �p -�I I� Q'Q .CONSTRUCTION LENDING AGENCY �'I4! �GGr/I /cam fY v v I hereby affirm that there is a construction lending agency-for the the performance of the-wo;k for which this,permit Is o o •.a • Issued (Sec' 3097,•Civ C) ,• • Lender's Name PROPOSED \ 2 Q6i8 7 MAX. OCC A 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, P and hereby authorize representatives of this County to enter IT FEE u n the above-m done pert f r i spection purposes SEE REVERSE FOR EXPLANATORY'LANGUAGE nature of Perm tte Date WORKERS'COMPENSATION DECLARATION Q-7375 M ISCELLANEQUS APPLICATION ' C 875 (11-84) ' ;I hereby affirm that I have a certificate of consent to self' ""i, 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 CompanyFOR APPLICANT TO FILL IN BUILDING �Q / ADDRESS vJ Certified copy is hereby furnished. BUILDING LOCALITY XX ADDRESS O S /7Lt'S Certified copy is filed with the county building inspection LOCALITY NEAREST department. yy yl, ,t CROSS ST Date Applicant NEAREST DISTRICT NO. GROUP TY Pfi ESSED BY CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL UQ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. OF LOGS. NO (CIRCLE) STATE MAJOR SECOND LOCAL _ (This section need not be completed if the Work involved TRACT NOW ONBLOTUSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF ` I certify that'in,the performance of the work for which this SIZE OF LOT EXISTING BLDG. permit is issued, 1 shall not employ any person in any,manneXX OWNER of buildingo oh so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP Date Applicant ADDRESS NOTICE TO APPLICANT If, after making this Certificate of CITY TEL OCCUPANT LOAD 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 oI this permit shall be deemed revoked. TRAILER USE GEOLOGY INSPECTION'S No Spec. Know!. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION El 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 fixlrs ness and Professions Code,and my license is in full force ar*X effect Name of business PARKING REQ•D 1 J PROVIDED • - SPACES L_...� License Number Lie Class t1 1 au { 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 INSP TOR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI N TORE mess and Professions Code).- FINAL APPROVAL Lie or Reg No Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS .ON LOT AND USE (% �^ ✓�� 1 hereby affirm that 1 am exempt from the Contractor's �'•� h✓ License Law for the following reason (Section 7031 5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, SPACES PROVIDED p p y, will do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED use of BUILDING 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 1 issued(Sec 3097,Civ C) Lender's Name , PROPOSED MAX.OCC. - Lender's Address PERMIT FEE 1 certify that I have read this application and state that the 25.00 above information is correct 1 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 25-00 on the above mentioned property for inspection purposes. XX ? XX SEE REVERSE FOR EXPLANATORY LANGUAGE aiure of Penniiiec Date