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Home My Public Portal About9400 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 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. Ji Company FOR.APPLICANT TO FILL IN BUILDING j� DD KESS G� Certified copy is hereby furnished. UILDING y� �IVLOCALITY A DRESS ' � El Certified copy is-filed with the county building inspection NEAREST department. LOCALIT�G� i T Del IROSS ST. Date Applicant NEAREST V O(/ DISTRICT NO. GROUP TYPE PR ESSED BY CROSS ST. 'CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `r COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (This section need not be completed if, the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) USE OF SI E OF LOT EXISTING BLDG. �'�1 I,certify that in the performance of the work for which this _ LLLss��.permit is issued, I shall not employ any person in any manner WNER I— so as to become subject to the Workers' Compensation Laws. AIL - T OCCUPANCY GROUP 6/ J b LLJ DRESS . L�t/r d ,r ' CL Date Applicant r C TEL' NOTICE TO APPLICANT: If, after making this Certificate of OCCUPANT LOAD TY m � �r No. 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 C3 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) 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. effgct. SPACES REO'D O PROVIDED 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 SIGNATURE acting in my professional capacity (Section 7051, Bus- (STING BLDG. STORIES mess and Professions Code). PRESENT USE OF BUILDING 1V,0 r gfj� FINAL APPROVAL Lic.or Reg.No. Date •C/ J HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that, I am exempt from the Contractor's z.1 2 7,51 R License Law-for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I#{O"o O - 88 SPACES PROVIDED 1, as owner of the property, will do the work and .the o 0 0 0 0 0 o z structureis not intended or offered for sale (Section 7044, Business and Professions Code). ( CONSTRUCTION LENDING AGENCY ) PROPOSED USE OF BUILDING I T �d��JI �2 I hereby affirm that there is a construction lending agency iCi for the performance of the work for which this permit•is issued(Sec. 3097,Civ.C.). Y/K Lender's Name PROPOSED MAX. OCC. Lender's Address PER'ro1IT FEE I.certify that I have read this application and state that the above information is correct.I agree to comply with all County IISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE ndhereby authorize representatives of this County to'enter __P. e above- entioned 4ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ' �ri1J OU Signature of Permittee Date y ,tel 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. ADDRESS f�O / LOCALITY ADDRESS lJ f^� 0 Certified copy is filed with the county building inspection OCALITYC'11 I NEAREST 1011 department. yn t, to CROSS ST. Date Applicant NEAREST I DISTRICT NO. G OUPTYPE PIR,9,MSSED BY CROSS ST. !�/ O a J CONST,, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `a f` COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL INC. OF HLDGS. (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. d I certify that in the performance of the work for which this ' ' �9 permit is issued, I shall not employ any person in any manner OWNER `�c c c e e� y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS I.— Date Date Applicant C3 TEL. LU NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD � Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: z 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. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION' Panic Devices 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 EXITS ness and Professions Code, and my license is in full force and effect. q'D tt PARKING PROVIDED E:=I �'�I SPACES RED License Number Lic. Class _ J 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 engineerslzE 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 —2&L a�J Lic.or Reg.No. Date �-/ V C+C- et n O = HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSL` 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 usi ness and Professions Code): NO. PARKING 0 I, 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 i L for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). P. C. Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE O>, above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and,State laws relating to building construction, r and hereby authorize representatives of this County to enter TOTAL, FEE S, upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature c errni tee Date WORKERS'COMPENSATION DECLARATION CE 875(1,1-84) MISCELLANEOUS APPLICATION CE 875 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 Workers'-Compensation Insurance,cr a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company - FOR APPLICANT TO FILL IN ABUILDING DDRESS Certified copy is hereby furnished. BUILDING G N/ S LOCI.LITY XX ADDRESS Certified copy is filed with the county building inspection LOCALITY p NEA:iEST department. may, ��' (. �(, ?}� CROSS ST. Date Applicant _ NEAREST DISTRICT NO. I GROUP TYPE CESSED BY CROSS ST. D� �f CONST. S' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �( COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF 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.) usI- 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 an mans. p p y y }{g OWNER of building -- so as to become subject to the Workers' Compensation Law,-.,. wa OCCUPANCY GROUP ® cc MAIL n U Date ADDRESS Applicant _ rEL. NOTICE TO APPLICANT: If, after making this CertificateoOCCUPANT LOAD O_ of CITY N . � 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 or this permit shall be deemed revoked. TRAILER USE E] GEOLOGY INSPECTION E] No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that 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 Professions Code, and my license is in full force amX effect. Name of business PARKING SPA��ES REQ'D � PROVIDED License Number Lia Class S� LL��J - LIMITED TIME USE Contractor Date •_ DATE DATE FI am exempt from the licensing requirements as I am':, FROM. TO: licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bu,- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). - PRESENT USE OF BUILDING FINAL APPROVAL / Lie.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 ✓IYr License Law for the following reason (Section 7031.5, Bus,- ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and thy, SPACES PROVIDED structure is not intended or offered for sale (Sectimi 7044,Business and Professions Code), CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agenc', for the performance of the work for which this permit is , I= issued(Sec. 3097,Civ.C.). a L.P• 7..=J Z LJ I_... Lender's Name PROPOSED MAX. OCC. ,. Lender's Address I_; PERMIT FEE ,y`€ I certify that I have read this application and state that th!, 25 . 00 { 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 4 4n upon the above-mentiQned property for inspection purpos ?' 3 SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX - -ii Signature of P niittce If to i WORKERS'COMPENSATION DECLARATION C CE 875 111-841 MISCELLANEOUS APPLICATION E 875 I hereby affirm that I have a certificate of consent to self" COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION J 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. BUILDING d 0 i �r`/ ADDRESS ADDRESS fk5 LOCALITY Certified copy is filed with the county building inspection LOCALITYTem le Cit ]NEAREST department. P y CROSS ST, Date Applicant NEAREST I�O DISTRICT NO. GRO TYPE CESSED BY CROSSo CONST I CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAGA L COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP RIC Rw Av NO. (CIRCLE) STATE MAJOR SECOND LOCAL 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 (SI00) or less.) USE OF I SIZE OF LOT EXISTING BLDG. 7- I certify that in the performance of the work for which this PLUFCL ty _ permit is issued, I shall not employ any person in any manner OWNER c a so as to become subject to the Workers' Compensation Laws. nnoREss (p V �N V OCCUPANCY GROUP ' 0 I Date Applicant L. NOTICE TO APPLICANT: If, after making this Certificate of CITY C,k�: ,� EZ:1 NO. OCCUPANT LOAD Exemption. you should become subject to the Workers' APPLICATION FOR cXIT HARDWARE: Compensation provisions of the Labor Code, you must forth i with comply with such provisions or rots permit shall be No N O I -' P. 15E GEOLOGY INSPE _ P i deemed revoked. TRAILER — - Spec. Knowi. I ,i LICENSED CONTRACTORS DECLAR.-kTION OCCUPANCY INSPECTION gg Fanic Devices I hereby affirm that I am licensed under provisions of Chapter — r: I 9 'commencing with Section ? SAFETY PERMIT LIST ITE.`.75 SELo 000) of Division 3 of the Busi- — I I No. OF EXITS L I ness and Professions Code, and my license is in full force and effect. feQ G �1 J� SPACES REO•J I� PROVIDED License Number L,c. Class LIMITED TIME USE Contractor Date ..TE OA TE u FFOM TC: [ am exempt from the iicensin@ requirements as I am i licensed architect or a registered �_rofessional encineer 517 of ND. o= INSPECTCR'S acting in my professional .:apacitn ISel tion -0-57. Bus- EXISTING SLOG. STORIES SIGNATURE = inessand Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING I 7 Lic.or Reg. No. Date HOME OR/NER-BCILDER DECL.1,RA-r,ON NO. OF EXISTING BUILDINGS 4\ k..... .. ON LOT AND USE O t4'; •rt-lY rf •� :._.y", !•.� I hereby affirm that I am exempt :rem the Contractors I License Law for the following reason 'Section '031.5, Busi- ness and Professions Code): NO. PARKING I, as oscner of the property. will do ate work and the ISPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING -AGENCY g PROPOSED USE of BUILDING 1 hereby affirm that there is a construction lending agency t i for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.I. Lender's Name PROPOSED MAX. OCC. Lender'sAddress I certifv that I have read this application and state that the PERMIT FEE 25.80 above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction. tt 1 and hereby authorize representatives of this County to enter TOTAL FEE 25.00 upon the abov ention property for inspection purposes. jSEE REVERSE FOR EXPLANATORY LANGUAGE v �Jigna`bdre of Permittee Date f ) WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N CE 875 (11-84) I sure, or a cert that I have a certificate of consent to c 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 FI LL IN BUILDING r� ADDRESS Certified copy is hereby furnished. BUDILDINRESSG J Qs, � ADm /) LOCALITY -�� Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST J DISTRICT NO. GR UP TYPE CESSED BY CROSS ST. {l "J rJ _ CONST, /� 1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v �f COMPENSATION INSURANCE DESCRIPTION I 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 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 n/ permit is issued, I shall not employ any person in any manner OWNER p��(a %Q I CNj y so as to become subject to the Workers' Compensation Laws. / OCCUPANCY GROUP EZ�� Date Applicant no IL DR ESS 0 �� lea ytey TEL '1 NOTICE TO APPLICANT: If, after making this Certificate of CITY �� No.. �/&� '7�� OCCUPANT LOAD c°n 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION F-1deemed revoked. ❑ El No Spec. Know). LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (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 ^,� I/ Sieffect, QOW- 0_T U 7 1I PARKING SPACES REq'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date / vG/ Gf� z • DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SI E o NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). e�; FINAL APPROVAL /- ��` �_ y PRESENT USE OF BUILDING 7�. J Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ji '` -� FP=- ON LOT ANI ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi �J t(i ;_=';j'iw j ( (_( 1-I i Js 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 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency ,e o 14( iamc S� for the performance of the work for which this permit is issued(Seca 3097,Civ.C.). ke " Lender's Name _ PROPOSED MAX. OCC. Lender's Address G(? 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 ordinances and State laws relating to building construction, and herepaut representatives of this County to enter TOTAL FEE a �. G6 upon the above ent' ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE l /I. 4d a ur Permittee - Date