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Home My Public Portal About9410 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444` Ik A q c //�� ® /� T A' r CE,875 (2-80) 1VOISCELL NEOu,s / PPLICM 1 ION Ihereby 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.) -' BUILDING. Policy No. Company FOR APPLICANT TO FILL IN > ADDRESS /4./'``�� ❑ Certified copy is hereby furnished. ADDRESS 0 - LAS � LocALITY Te ❑ Certified copy is filed with the county,buil ding inspection �, _ NEAREST department. LOCALITY PLE C e �� L 35 ivt�R�i C ROSS,ST.. Date Applicant AREST ]� ''DIST.RICT NO. G O TYPE PR SSED BY CROSS - ALFISSAN V :�_ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �' COMPENSATIONINSURANCE T DEscalPnoN LOT NO BLOCK MAP !I d (CIRCLE) HIGHWAY S NO. (CIRCLE) _ - O TATE MAJOR SEC NDLOC AL NO. OF BLDGS.- (This,section'meed 'not be completed if the work involved RACT NOW ON LOT USE ZONE SPECIAL'CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE'OFSIZE OF LOT EXISTING BLDG. I certify that in the performance of'the work for which this O permit is issued, I shall not employ any person in any manner 910fNER �� F so as to become subject to the Workers' Compensation Laws. jRS�& �� OCCUPANCY GROUP _ ,w ' tDL,j - _ Q.Date Applicant. , I NNOTICE'TO APPLICANT: If, after making this Certificate of C! T L. (p—�Z� OCCUPANT LOAD_ Z Exemption, you should become subject to the Workers' APPLIC TION FOR -EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE O GEOLOGY INSPECTION No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION occuvwrvcY INSPECTION Panic Devices ❑ 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. PARKING SPACES REq'D,O PROVIDED O License Number. Lie.Class LIMITED TIME USE C011tractor Date DATE DATE - ❑ I am exempt from the licensing,requirements as I am a CTO R'S licensed architect or a_registered professional engineer SIZE OF IGNNO. OF IN N acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ATURE. iness and Professions Code). P NT USE OF BUILDING FINAL APPROVAL Lie.or Reg.No. Dateve NG HOME OWNER-BUILDER DECLARATION ON LOTrAND USE NO. of Exl UUSE sulLDlrvcs . 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 �- � �� - • 0 I, as owner of the property, will do the work and the #.®;o O'.0 8 8 structure is not intended or offered for sale (Section 7044, Business and Professions Code). m • O m O O m N. OPOSED USE OF BUILDING / _ CONSTRUCTION LENDING AGENCY O`n000 4,23 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 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 and hereby authorize representatives_of this County to enter p P y p P P SEE REVERSE FOR EXPLANATORY LANGUAGE upon the above-men ' ne r ert for ins ecti n ur oses. r ,j� y Ignatu of Permittee"- Dae WORKERS'COMPENSATION DECLARATION 76M444 ' CE 875 (2-80) MISCELLANEOUS APPLICATION I hefiby- 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 BUILDESSING �] - ADDR `(/ �- � 'x{iC•�l/ ❑ Certified copy is,hereby furnished. BUILDINGS S LOCALITY Cl DDRESS "�ij V /. ry l/' - ❑ :Certified copy is filed with the county building inspectionNEAREST department. �ocALITv I� .'V. CROSS'ST. Date Applicant NEAREST -DISTRICT NO.- GROUP TYPE - PROC SSED'BY _,,,/// - CROSS ST. - ._ , J� �� CONST./ . CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G DESCRIPTION'. LOT.NO. ' BLOCK MAP IGH A COMPENSATION INSURANCE ND, ' .,Or(, RCLE) STATE MAJOR SECOND LOCAL d' NO. OFBLDGS. I (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 OFi - SIZE OF LOT EXISTING BLDG.. I certify that in the performance of the work for which this , R permit is issued, I shall not employ any person in any,manner wNEU so as to become subject to the Workers' Compensation Laws, MAIL . OCCUPANCY GROUP /(Jnr tL DD_RESSa Date Applicant to NOTICE.TO APPLICANT: If, after making this Certificate of irY NOL — OCCUPANT LOAD z Exemption, .you should.become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLIC TION FOR EXIT HARDWARE: with comply, with suchprovisions or this permit shall be - TRAILER.USE GEOLOGY INSPECTION O - No Spec. KnOWl. El - deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ 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 PARKING effect. SPACES REO'D PROVIDED License Number Lic.Class LIMITED TIME USE �J Contractor Date D AT E DATE ❑ - FROM: T O: _ 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 EXISTINGBLDG. STORIES /fSIGNATURE mess and Professions Code). _ RESENT USE OF BUILDING FINAL APPROVAL ' Lic.or Reg,No: Date' �i�� 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 I, as owner of,the property, will do the work and the 20,1-a,4 A structure is not intended or offered for sale (Section t O 7044,Business and Professions Code). # e:b o o (1 ROPOSED USE OF BUILDING - CONSTRUCTION LENDING AGENCY _ r I hereby affirm•that the'r.e'is a construction lending agency vCE - , 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 - I certify that I have read this application and state that the above information is correct.1 agree to comply with all County ISSUANCE Fee ordinances and State laws relating to building construction,'' nd hereby' uthorize representatives of: his County to-enter TOTAL FEE _ -- - upon the ve- ti Tied proper f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i ure of Permittee Date WORKERS'COMPENSATION DECLARATION7E MISCELLANEOUS A P P L I C AT'I O N J� 875 .all CE 875(11-84) 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(See. 3800,Lab.C.). BUDRESILDING G fl AD Policy No. Company FOR APPLICANT TO FILL IN ! ) S FICertified copy is hereby furnished. UILDINGqL�Jn- F^ ADDRESS LOCALITY t' ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. cRoss sT. Date Applicant EAREST DISTRICT NO. GROUP TYPE PR ESSEOt BY CROSS ST. 06k Ave' ��D g � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (f COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHW AV rvo. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS: (This'section need not be completed if the work involved TRACT NOW.ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF slzE of LOT EXISTING BLDG. I certify that in the performance of the work for which this. o r a . � permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP; �� ?� o ADDRESS I O `` i ` �l`\_ \,-.�,"" i 1\.., t (- Date Applicant - - , 0- NOTICE TO APPLICANT: If, after making this Certificate of CITYle A DIOL OCCUPANT LOAD Z Exemption, you should become subject to the Workers' APPLI ATION 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. 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 and effect. PARKING SPACES REQ'D PROVIDED l� License Number Lie. 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 acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code). NT USE of BUILDING FINAL APPROVAL X� Lic.or Reg.No. Date ho HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDIN SG 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- nessand Professions Code): NO. PARKING ElI, 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). OPOSED USE OF BUILDING �: CONSTRUCTION LENDING AGENCY 4I I hereby affirm that there is a construction lending agency for the performance of the work for,which this permit is h 801 1 l d - issued(Sec.3097,Civ.C.). Lender's Name ^ W) PROPOSED MAX. OCC. Lender's Address v S Ory 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, and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned operty for inspection.purposes. _ ` SEE REVERSE FOR1EPLANATORY LANGUAGE Signature of Permittee 15ate WORKERS'COMPENSATION DECLARATION 76M444 . MISCELLANEOUS APPLICATION' I hereby affirm that I have a certificate of consent to self CE 875(11-84) �. insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILUI9G`fAND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING qq Q X ' ADDRESS L„IS TaruRS 79K- LOCALITY Certified copy is filed with the county building inspecti LOCALITY NEAREST department. �3M CROSS ST. Date Applicant \\ 'NEAREST ' a /� DISTRICT NO. GR UP TYPE P CESSED BY CROSS ST. LAS 7U N+Q 7 ALaXs +D�� --e7 � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY NOOF BLDGS. No. (CIRCLE) STATE MAJOR SECOND LOCAL . (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. 0. I certify that in the performance of the work for which th' o N 55e— permit is issued, I shall not employ any person in any mann X N9wNER Of bulldlri p so as to become subject to the Workers' Compensation Laws>_� MAIL OCCUPANCY GROUP U Date ADDRESS li=Applicant L, L. NOTICE TO APPLICANT: If, after making this Certificate of CITY N0 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 INSPECTION ❑ No Spec. Knowl. deemed revoked. 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 EXITS ness and Professions Code, and my license is in full force anix 1Q ZIIle of business PARKING effect. ^p SPACES REO'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FRD M: I am exempt from the licensing requirements as I am a TO: licensed architect or a registered professional engineer SIZE OF NO. OF INS PE TO R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sI rURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING ` •�•4 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 ' 0 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 i issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address `" PERMIT FEE25. 00 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 I ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 ._00 upon e abo -menti n pro erty f r inspection purposes. EE REVERSE FOR EXPLANATORY LANGUAGE XX -rs Signature of Permittee Date