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Home My Public Portal About9413, 9413 1/2, 9415, 9417 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION (b"1444 MISCELLANEOUS APPLICATION 20-0063DPW?2/90 I hereby affirm that I have.a certificate of consent to self COUNTY OF LOS ANGELES BUILDING:AND SAFETY DIVISION insure, or a cen:ifieate of:Workers'Compensation Insurance,or a certified copy thereof (Sec. 3800, Lab.C.)" 1 Policy No._ Company FOR APPLICANT TO FILL IN BUILDING ' BUILDINGADDRESSADDRESS ❑ Certified copy.is hereby:furnished. X Q/4 4 W fle2£1 uQSE C./1'S f,;rrJ-S LOCALITY ❑ Certified copy is filed with the county building inspection CITY ZIP NEAREST, department. TQM Pt,E C eA q l -7 8-c> cRoss sr. Date - _Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY n coNsr. CERTIFICrqE OF EXEMPTION FROM WORKERS' TRACT BLOCK LOT NO. C I .I-OMPENSATION INSURANCE - NOP CRc EI STATE MAJOR SECOND LOCAL.. (This section (teed not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS C9 by the permit is for one hundred dollars ($100) or less.) su>$ari`y e TEL NO. f I.certify that is the performance,of the work for which this NI 1a SI tfi permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. ADDRESS �pN f 2LY �� OCCUPANCY GROUP Z r Date 4 t>3 Applicant . 4ut 6i/ko �-+� �� CITY ZIP — NOTIC O APPLICANT: If; after making this Certificate s" D NR C-4 gto3o OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE: ( comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ NO Spec.Knowl. ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) C'a 9(commencing with Section 7000)of Division 3 of the Business NO.OF EXITS and Professions Code.and my license is in full force and effecr. .,Name ot Bustness ' I PARKING• REO'D D PROVIDED O License Numbei Lic. Class l'Ct)N p 2 a-F- SPACES t I i Contractor — Date _ LIMITED TIME USE ❑ I am exem.)t 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 NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES SIGNATURE. Lic. or Reg. No._ Date / PRESENT USE OF BUILDING FINAL APPROVAL e>3 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,X PROPOSED USE OF BUILDING Business ant Professions Code). r � I 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.). PROPOSED MAX.OCC. Lender's Name _ APPLICANT(PRINT) TEL NO. Lender's Address ADDRESS I certify that I have read this application and statethat the '�'� Q9" If-t-I L C\'fy t above information is correct. I agree to comply with all County PERMIT FEE ordinances and Si:ate laws relating to building construction,and hereby authorize representatives.of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. t .I TOTAL FEE - X SEE REVERSE FOR EXPLANATORY LANGUAGE Sienatu a of ennittee Date 1. WORKERS'COMPENSATION DECLARATION CE 875(11-84)= I�'� CE 875 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. Company FOR APP LI CANT TO FILL IN BUILDING Certified copy is he ADDRESS furnished. BUILDING / ADDRESS r LOCALITY Certified copy is filed with the county building inspectionLOCALITY NEAREST department. `P_ CROSS ST. Date Applicant NEAREST DISTRICT N . GR UP ITYPE1R.C.7SSED BY CROSS ST. - CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. F BLDGS. NO. (CIRCLE) STATE MAJOR SE' LOCAL - (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT - EXISTING BLDG. 1 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 o so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP' E10 ADDRESS o k .sc E3 Date Applicant TEL OCCUPANT LOAD o_ NOTICE TO APPLICANT: If, after making this Certificate of c I T Y ` NO -S cla C1 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 oI this permit shall be TRAILER USE ❑ deemed revoked. GEOLOGY INSPECTION ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM T ❑ 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 REq'D SPACES D PROVIDED 11 J License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a FROM: TO: 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 ifessionsCode). Lic.orrReg..No. Date FINAL APPROVAL PRESENT USE OF BUILDING O r• ReNo. �\ q p HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Z,$5 1,,3 ON LOT AND USE 0;0 0 0 S I hereby affirm that I am exempt from the Contractor's 0 o D o 0 0 a z License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 'I EDI, as owner of the property, will do the work and the SPACES PROVIDED `�� I'2 0 6;-8 7 structure is not intended or offered for sale (Section �\ 7044,Business and Professions Code). \ CONSTRUCTION LENDING AGENCY ROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. .. _ Lender's Address too certify that I hav read this application and state that the PERMIT FEE_ t above information is rr t.I agree to comply with all County ISSUANCE FEE ordinance and Stat v relating to building construction, BO and here uth ' e r sentatives of this County to enter TOTAL FEE u on the e- n roper for' ction purposes. q� EE REVERSE FOR EXPLANATORY LANGUAGE SigrLat r 't e Date WORKERS'COMP,EN$ATION DECLARATION ` -CE 876(2-80) `• M 1 SC E L LA N. E 0 Q S A F'P,L I C A T I O N. I hereby, affirm that I.have a"certificate of consent to self insure, or a certificate of`Workers'Compensation'Insurance,or ., COUNTY OF' LOS ANGELES ; -BUILDING'AND SAFETY DIVISION A certified-copy thereof(Sec,,3800;Lsb:'C.) Policy No. CompanyFOR APP LICAIVT TO FILL-I N' BUILDING .. - _. ADDRESS •3 - Certified;copy`is hereby furnished. BUILDING / LOCAL171Y.-. , /yam /'►.c .' .. ,T •. . ADDRESS ! /3 /... f�rJ V'/v�JLJ_ J/�.� •i 'Certified cop'y:is`filed with the•co6nty building inspection' NEAREST ' LOCALITY �j�.}�(/�/ •�� ` depa[tment. L CROSS ST. Date Applicant c _ NE A'R EST- C DISTRICT NO... GR UP ]:COTYPE - PR SSE BY • - CROSS DESCRIPTION •,L S� NST �j /] ,CERTIFICATE OF-EXEMPTION FROM WORKERS LEGAL / , ,.. OTNO�. '• ,._ BLOCK .�; .. COMPENSATION INSURANCE MAP "IGT wAv ' ,... .. _ ,.NO. (CIRCL'EIt -STATE .(This section .need not,be.completed if the•work ,involved TRACT Now ONB ors USE ZONE SPECIAL CONDITIONS MAJOR SECON LOCAL' .Q. 0 by the permit is.for one hundred dollars ($100):or less.) V- USEOF SIZE OF LOT EXISTING BLDG. I certify that in the perforinance'of the work for'wtiich this OWNER :,permit is issued, I shall not empl'oy'any'person,I any manner,' U so as to become subject.to the Workers' Compensation Laws. MAIL Y OCCUPANCY GROUP J1 r2 a 1 .- ADDRESS Cn Date ,Applicant- `o NOTICE TO APPLICANT: If, after makingthis Certificate'of CITY' i. rTioL a OCCUPANT LOAD z Exemption, you should •become',,subject to the Workers' APPLICATION FOR, -.EXIT HARCWA'RE: Compensation provisions of the Labor Code, you must forth-+ With comply with such'-pro isioris OC this-permit shall be TRAILER USE GEOLOGY INSPECTIONNo Spec: KnowFElo deemed revoked - - . Panic Devic es ❑ .00CUPANCYINSPECTION - " LICENSED CONTRACTORS DECLARATION t ❑ ' Thereby affirm that I am licensed under provisions of_Chapter SAFETY PERMIT'q (LIST ITEMSBELOW) ,9 (commencing with Section 7000) of Division 3 of the, Busi No. OF'-EXITS f, - ness and Professions'Code, an'd my_license.is.in full force and' Cffect. KING. ' O PROVIDED PAR REOD D SPDC ES License Number-. Lic.Class LIMITED .TAME USE Contractor ;Date DATE: DAT- TO: EJI am exempt from the licensing requirements_'as 1 am a: ' _ licensed architect ,or -a registered 'professional engineer, s1zE of IVS croR's NO. OF ' 1 P acting,in my professional'capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE' 'iness and"Professions Code)-- ,- 'PRESENT_ - FINAL AF'PROViAi USE OF BUILDING O - /F G �/ , ,Lic.or Reg.No.: Date HOME OWNER BUILDER DECLARATION 1 NO, OF EXISTING BUILDINGS �A1 L ON L•OT AND USE'• 1.0 Q 6:11 I hereby affirm that .I am exempt from-the;.Contractor's License 'Law for.the"following reason (Section 7031.5, Busi- # • NO. PARKING - ness and Professions Code SPACES PROVIDED I;'as,owner sof the property;,will do the work and the o o'o 0 0 0 0 structure'-is y not intended or'offered for. sale (Section:', - 5 4 PROPOSEDUSE OF BUILDING V 1• J7 8 4 7044,Business and Professions Code) ; : BN . - - /^/ _ CONSTRUCTION LENDING AGENCY I hereby affirm that there'is a construction lending agency forthe performance of the,.work for which this-permit is'' issued.(Sec.•3097„Civ.C.). Lender's Name _ ...... - PROPOSED MAX: OCC: Lender'S:AddrCSS PERMIT FEE ...'-.' r I certify Ithdt I have read 'this-application,'and:,state.that the . above information is correct. I agree-to comply with all County ISSLI'ANCE'FEE ordinances' and,State laws relating to`building construction,-,. and hereby auth rize'representatiu f—fff's Counfy.to'enter rorwt.FEE u on th a# entib o erfy ins ection r ores. P p Y P P p SEE REVERSE FOR.EXPLANATORY'LANGUAGE _ Signature of Per ittee. ate: