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Home My Public Portal About9251 LAS TUNAS DR_Miscellaneous__ winMollitifi,cate ERS'-COMPENSATION DECLARATION 7E 8754 2$0l MISCELLANEOUS APPLICATION , m that I have .a certificate of consent to self of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800, Lab.C.) BUILDING Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is,hereby furnished. BUILDINGLOCALITY j ADDRESS C. i—A - V1l➢ S /'� ❑ Certified copy is filed with the county building inspection NEAREST o• v department. ocALITY ! CITY [CROSS ST. Abcs io—ALO�6 Date Applicant AREsr e nG y�/j DISTRICT NO, GROUP TYPE PROCESSED BY CROSS.ST. /T L�SS/'/�F�/�O Aoc - CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK HIGHWAY COMPENSATION INSURANCE NO. (CIRCLE) STATE MAJOR SECOND LOCAL a NO. OF BLDGS. (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. tl. 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 V 1� I— so as to become subject to the Workers' Compensation Laws. UJ FD?RE - 1, OCCUPANCY GROUP SS, riDate Applicant to Z NOTICE TO APPLICANT: If, after making this Certificate of t �A — OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- A PLICATION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USE r GEOLOGY INSPECTION NO Spec. Knowl. El revoked. Panic Devices ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION - I hereby affirm,that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) No. of Exlrs ❑ 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. PARKINGSPACES REO'D D ' PROVIDED License Number Lic. Class LL��JJ LIMITED TIME USE Contractor Date DATE DATE El - 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 SIG TURE iness and Professions Code). ESENT USE OF BUILDING FINAL APPROVAL _ Lic.or Reg.No. Date p E A /7�. HOME OWNER-BUILDER DECLARATION ON LOT'AND NO. OF *ANDEXISUSE: BUILDINGS 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 ❑ I, as owner of the property, will do the work and the #z'J 6 5 O structure is not intended or offered for sale (Section a-o o. o ZS 7044, Business and Professions Code). a a o O's o e u) ROPOSED USE OF BUILDING - Z CONSTRUCTION LENDING AGENCY 2,] J-8 5 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 •� a 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, TOTAL FEE V` and hereby authorize representatives of this unty to enter u n the above-mentioned property for i pection purposes. SEE,REVERSE FOR EXPLANATORY LANGUAGE )--?�-7- Si nature of P ittee Date - WORKERS'COMPENSATION DECLARATION C CE 875(11-84) MISCELLANEOUS APPLICATION E 875(1 �I hereby affirm that I have ,a certificate of consent to self COUNTY OF LOS ANGEL=S 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 BUILDING/ ADDRESS FICertified copy is hereby furnished. BUILDING �5 SU S Dr LOCALITY XX ADDRESS Certified copy is filed with the county building inspection LOCALITY �yy�PL�+` / NEAREST department. 30r, Cil'IC� /" CROSS ST. Date Applicant NEAREST DISTRICT NO. G OUP TYPE CESSED BY pp CROSS ST. LESSf}1VPg0 CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIALCO NDITIONS by the permit is for one hundred dollars ($100) or less.) USE of OF�� SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this /d -- Ltl CD o' permit is issued, I shall not employ any person in any mannekX OWNER of buildingV�I L -/ r Z so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP � ADDRESS r" Date Applicant Q ¢ / p uvJ TE NOTICE TO APPLICANT: If, after making this Certificate of CITY TN .°2�3)(JSp �(��ZO 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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTIONE] No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 anX Name of business PARKING r� - effect. py'/ //IY�/ /�� REq�D I I PROVIDED License Number Lic. Class 4 f 10� G/ T V (D/N SPACES LL_=� LIMITED TIME USE Contractor Date DATE DATE El I am exempt from the licensing requirements as I am a R licensed architect or a registered professional engineer slzE of NO. OF INSPECTOR'S acting in my professional capacity apacity (Section 7051, Bus- EXISTING BLDG. STORIES SI79ATURE iness and Professions Code). FINAL APPROVAL id_z_qs� Lic.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's U V License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING (` ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section I 1 ,`ri '^ 6 7044,Business and Professions Code). V 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 T issued(Sec. 3097,Civ.C.).Lender's NamePROPOSED MAX. OCC. __Lender's Address F PERMIT FEE �"'11: 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 ('Y� ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 T? upon b ve mentione p �operty r inspection pu poses.Q x 1`I X ��%Gt_l XX� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee bate I i, '*J: