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Home My Public Portal About9245 LAS TUNAS DR_Miscellaneous__ 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,certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. aUILDING ADDRESS I LOCALITY Certified copy is filed with the county building inspection LOCALITY C� NEAREST department. (�� Ckk v cRoss sr. Date Applicant NEAREST DIST CT f lIIYYYPPP))) TYPE P CESSE Y CROSS ST. G CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 3 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND OCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT I 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. d I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP Iz MAIL' ` O ADDRESS �� o ` C-3 Date Applicant IJJ TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY No. �y Exemption, you should become subject to the Workers' z 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. I Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (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 �� x� effect. G' PARKING SPACES READ D PROVIDED License Number Lic. Class LIMITED TIME USE �J Contractor Date DATE DATE 0 1 am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO: OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE iness and Professions Code). PRESENT USE OF BUILDING () ()..�' Q,� FINAL APPROVAL r Lic.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 !.l3_=�-9 i�e 3� I, as owner of the property, will do the work and theSPACES PROVIDED7'Irl f ; structure is not intended or offered for sale (Section H ' 7044,Business and Professions Code). y� 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 \ 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 1 ordinances and State laws relating to building construction, anhereby authorize representatives of this County to enter TOTAL FEE , Vu u on the above -ment' ned property for inspection purposes. Ns SEE REVERSE FOR EXPLANATORY LANGUAGE VAA 0\ ign re of Permittee Date ( I WORKERS' COMPENSATION DECLARATION z000ssDPvt,zisn MISCELLANEOUS APPLICATION I hereby affirm that 1 have_a certificate of consent to self COUNTY OF LOS ANGELES BUILDING: AND SAFETY DIVISION insure, or a certificate of Wotkers'Compensation Insurance, or • a certified copy thereof (Sec. 3800, Lab.C.): - Policy'No. Company FOR APPLICANT TO FILL IN BUILDING BUILDING-ADDRESS ADDRESS ❑ Certified copy.is hereby;furnished. X 4,$ %(i/ULOCALITY ❑ Certified copy is filed with the county building inspection CITY zipr� department. / �'� f T j 71 7NEAREST CJ�-' CROSS ST. Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY - CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' ( I 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 BOOK PAGE PARCEL by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS 1. certify that in the performance.of the work for which this Fir 00f er TEL No, permit is issued, I shall not employ any person in any manner lr K LA= 3z3-80 i(tr,r�? so as to become subject to the Workers' Compensation Laws. ADDRESS 33 OCCUPANCY GROUP P o II Date Applicant CITY^^ ZIP C91 NOTICE TO APPLICANT: If. after making this Certificate /tt ! J I OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of theLaborCode.you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ 1- No Spec.Know]. 1:1revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ Panic Devices ❑ I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) ',� t I 9(commencing with Section 7000)of Division 3 of the Business Name o uslness NO.OF EXITS _ and Professions Code,and my license is in full force and effect. .- PARKING• REO'D PROVIDED License Number Lic. Class SPACES �J Pel% Cl�c� 1r5� S 2 ( I Contractor Date LIMITED TIME USE 3' ! ❑ I am exempt from the licensing requirements as I am a DATE DATE FROM: To: licensed architect or a registered professional engineer acting in my professional capacity (Section 7051,Business SIZE OF �� S. NO.OF INSPECTOR s {` I and Professions Code). EXISTING BLDG. STORIES` _ SIGNATURE, Lic. or Reg. No. - Date PRESENT USE OF BUILDING FINAL APPROVAL vL 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, Business 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 7044,1 PROPOSED USE OF BUILDING Business and Professions Code). ( AF'F+Cr A04K �? flPr(lC 1�1=Sf CONSTRUCTION LENDING AGENCY ?flP�_ (tiJ..1ii�1NCa t�t►dfr7.'lC I-hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ( i (Sec. 3097, Civ.C.). PROPOSED MAX.OCC. Lender's Name APPLICANT(PRINT) Lender's Address ADDRESS I certify that I have read this application and state that the 4� tl tv 4S DA above information is correct I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives.of this County to enter upon ISSUANCE FEE above-mentioned property for inspection purposes. tea - TOTAL FEE U % SEE REVERSE FOR EXPLANATORY LANGUAGE : Signature of Permittee Date L • ;;ORKLRS' CODIPhNSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 1 hereby affirm that I have a certificate of consent 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.`— CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS Certified co is hereby furnished. UI'DI" ,( Py y XX ADDRESS L ftS PQ LOCALITY F1Certified Copy IS filed\vith the county building inspection LOCALITY re m�t� /, q' � ;G r7&o NEAREST department. $}r, 1 l�R7 / CROSS ST. Date- —Applicant _ NEAREST �j /ry�� DISTRICT NO. GROUP TYPE y. P OCE$SED BY CROSS ST. GSS L"✓I� �� CONST^7 CERTIFICATE OF EXEMPTION FROM WORKERS' c LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIGH.AY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. ('['his 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 (S100) or less.) EXISTING of E SIZE OF LOT XISTING BLDG. p certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mannexx WNER Of buildin ,4iqh t LCf/, 0- so as to become subject to the Workers' Compensation Laws' MAIL /�/I OCCUPANCY GROUP of Date_ ____ Applicant _ _ /J J ry u- g �n�o h2� / TEL/L ( �(J��n/� OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY J� No. e2 v Exemption, you should become subject to the Workers' �75 APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth with comply xylth such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION El Devices ❑ LICENSED NSF.0 CONTRACTORS DECLARATION 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 Professionu Code, and my license is in full force a effect. nix--Name of business PARKING License Number Lic. ('lass (f,'"'Ow& CA -PE�+-s Co SPACES REQD D PROVIDED^F ' Y=•r-•- LIMITED TIME USE Contractor Date DATE DATE TO:[t�y 11 t-Ilt Ill! it it �•1'�i 1 am exempt from the licensing requirements as I am a FROM: 9.4 licensed architect or a registered professional engineer SIZE OF NO. OF i IN SPE CSQ R($ [ acture In my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES i SIGNWIUR E' iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVALIld-zS, L Lic.or Reg. No. Date f� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS f;',1 I ON LOT AND USE D 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 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 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—.----- 25 . 00 1 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 representatives of this County to enter TOTAL FEE 25. 00 upo the above-mentioned property for inspection purposes. XX Ii7 G5� SEE REVERSE FOR EXPLANATORY LANGUAGE XX C. ' �ir.n;iinrc ��f I'I•rmitttr D:IIe � r WORKERS'COMPENSATION DECLARATION CE 375(11-84) MISCELLANEOUS APPLICATION CE 875 . I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANC',ELEg BUILDING :IND 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 BUILDING ADDRESS T Certified copy is hereby furnished. BUILDING m' ++• l.i' y J 1 LOCALITY ADDRESS 1 L'1 Lam. 1. `} department.Certified copy is tiled with the county building inspection LOCALITY Temple City NEAREST. Date applicant NEAREST TYPE OGESSED BY CROSS ST. .� �..J CONST l CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �4 COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP I.. AY NO. (CIRC Lf) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (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 (S100) or less.) usa of SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner X OWNER VALIANT K. LAI so as to become subject to the Workers' Compensation Laws. I� , OCCUPANCY GROUP •O• 80Y 333Mcnterey Parc CA y! Date .applicant ADOR ESS91 NOTICE TO .APPLICANT: If, after t, rtiticate of CITY o TEL. OCCUPANT LOAD �IOnt...re_� Par'c NO. ( 323 ) 988-602 Exemption, you should become bj to th Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Lab r C de, you z ust forth- with comply with such pIOvisions or S e shall be TRAILER USE L GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices J I herebv affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing %vith Section 7000) of Division 3 of the !Susi- NO. OF EXITS ness and Professions Code, and my license is in full-force and effect. _ PARKING REWD PROVIDED SPACES l License Number Lic. Class LIMITED TIME USE Contractor Date DATE .ATE RRO M: 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 .inus and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg. No. Date o ) HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS JJ ^ ON LOT AND USE I hereby affirm that I am exempt from the Contractor's following reason (Section 703L5, Busi- J License Law for the I `T ness and Professions Code): NO. PARKING 1. as owner of the progeny, will du the work and the SPACES PROVIDED' structure is not intended or offered for sale (Section ) 7044,Business and Processions Code). Y X PROPOSED USE OF BUILDING Of f ice space 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 I certify that I have read this application :Ind state that the PERMIT FEE 25.DU _ above information Is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws anrelating to building construction, and iierebv authorize representatives of this County to ter I TOTAL FEE 25.00 _) upon the above-mentioned property for inspection purposes. SLE REVERSE l'OR EXPLANATORY LANGUAGE Signature of Permittee Date