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Home My Public Portal About9925 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8754(2-s0) IbI I SC E L LA N E O U S� APPLICATION , I reby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION inre, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec' 3800,Lab C.) Policy No Company BUILDING 'rj,,, ✓� FOR APPL'ICANSTO FILL IN AUILDIN DDRESS Certified copy'Is hereby furnished. UILDING //1� LOCALITY Q ADDRESS Gr7�/ L/7 �( A Certified copy is filed with the county building inspection NEAREST department OCALITY' CROSS ST. �� 14A_ Date Applicant IIAREST ./ DISTRICT,NO GR UP JPRO�&ED-,BY, • CROSS 3T. L /V ,, ' � P11LYPEV_ CONS 'CERTIFICATE-OF EXEMPTION FROM WORKERS' LEGAL D COMPENSATION INSURANCE „ DESCRIPTION LOT,NO. BLOCK MAP ` HIGHWAY } rIo (CIRCLE) STATE MAJOR SECON LOCAL a NO. OF BLDGS (This section,need not be completed-if the work involved 'TRACT NOW ON LOT USE ZONE[71 CONDITIONS O 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 thisy m v• O permit is issued, I shall not employ any person in any-manner WNER' F7&2 so as.to become sublect'to,the Workers' Compensation Laws OCCUPANCY GROUP AIL W Date ApplicantAD .ESS o?S�• s 7Z.'A4f-r �/v,6 a nTEL NOTICE TO APPLICANT If,-after making,this Certificate of eITY TE/hPG� C/]^y , NO OCCUPANT LOAD ' Z Exemption, you should become subject to -the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth= ti with comply with such provisions or this permit shall be TRAILER USE - GEOLOGY INSPECTION deemed'revoked.' O No Spec. Knowl. 0 n LICENSED CONTRACTORS DECLARATION , OCCUPANCY INSPECTION Panic Devices a I hereby affirm that I air licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS,BELOW) 9 (commencing with Section 7000)oNO.-OF EXITSf Division 3 of the Busi- — ' _ , ness and Professions Code, and my license is in full force and I ' effect PARKING SPACES REO'D O PROVIDED O License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements a`s I am a licensed architect' or a,registered professional engineer SIZE OF NO OF FROM, TO INS ECTofx's acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES GNATUR Inessand Professions Code) FINAL APPROVAL _ RESENT USE OF BUILDING Lie or Reg No. Date %��%� CJ 4 I1 # 0 0 0 . 8 8 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 SPACES PROVIDED 0 1, 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 FoR 7I� ®ASC n� 0r .2>V71 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 aRo'vosED MAX occ Lender's Address PERM IT-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 _ O ordinances and State laws relating to building construction, rorAL FEE and hereby author resentatives of this County to enter upog th o e-m roperty for inspectn purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 61j,/,?c re o Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-64) MISCELLANEOUS APPLICATION �- • CE 875 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS A;VGE:.ES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). BUILDING r Policy No. Company FOR APPLICANT TO FILL IN ADDRESS /O�✓ �� Certified co is hereby furnished. BUILDING q q ,.Q,� copy y XX ADDRESS LOCALITY El Certified copy is filed with the county building inspectionLOCALITY «/�OO NEAREST department. 30r. eJ( o CROSS ST. Date _Applicant NEAREST DISTRICT NO� GRgUP TYPE P ES4ED BY CRO33 ST. _RI CT N^/ �Q//`J� CONST. CFiR till ICA"fE OF EXEMPTION FROM WORKERS' LEGAL Lt COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIGI.WAr NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (Tills 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 cS permit is issued, I shrill not employ any person in any manneXX OWNER of buildingJ so as to become subject to the Workers' Compensation Laws. —MAIL OCCUPANCY GROUP ADDRESS U Date_ Applicant a L I NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL o?��"�� J OCCUPANT LOAD Q-3 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 ❑ No Spec. Knowl. cieenied revoked. OCCUPANCY INSPECTION ❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I ain licensed under provisions Of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) a 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS nes, and Professions Code, and my license is in full force an*X Name of businessqh§ PARKING effect. SPACES REQ'D PROVIDED License Number___ _____.._— Lic. Class LIMITED TIME USE tontMctor_. Date DATE DATE PROM: 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 iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL. Lic.or Reg. No. Date �p IIOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I ani exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, 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 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 ` t'' I cerlil'y that I have read this application and state that the 00 above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, -!m and hereby authorize representatives of this County to enter -TOTAL FEE 25 -00 upon thXV ntioncd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX --... --- - -I, ... .,. - I .I..