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Home My Public Portal About9415 LAS TUNAS DR_Miscellaneous__ COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION � - -- CE 875 I he atfirm 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. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS FICertified copy is hereby furnished. UILDINGGf( ADDRESS ,) � LOCALITY 0 Certified copy is filed with the county building inspection OCALITY1 _ NEAREST department. t C CROSS ST. Date Applicant XFAREST DISTRICT JJf``��IO. G OUP TYPE PR SED BY CROSS ST. i Jl �� CONST,, / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY . NO. (CIRCLE) STATE MAJOR SE OND LOCAL ' - NO. OF.BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USEONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF (Q 'O SIZE OF LOT E STING B DG. �e r 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 so as to become subject to the Workers' Compensation Laws. AA AILOCCUPANCY GROUP- a ADDRESS `f 1--' Date Applicant f3 TEL.C/ NOTICE TO APPLICANT: If, after making this Certificate of CITY. No. 7�� OCCUPANT LOAD ° 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices E 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 ProfessionsCode, and my license is in full force and effect. PARKING SPACES ,REQ'D D PROVIDED •� 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 engineersde OF NO. OF ]INSPECTOR'S acting m my professional capacity (Section 70S1,•Bus- EXISTING BLDG. STORIES S NATURE _. ...._ inessand Professions Code)._ FINAL APPROVAL PRESENT USE'OF.BUILDING 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 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 5 14L 6 A SPACES PROVIDED - '- 1, as owner of the property, will do the work and ,the # m:• m m 8 8 structure is not intended or offered for sale (Section ° °' z . 7044,Business and Professions Code). for' sale CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency TT c 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 an to laws r ating o building con ruction, and hereby th r t i s of this Count to ente TOTAL FEE upo th o for inspe do p rpose f SEE REVERSE FOR EXPLANATORY LANGUAGE Date Sign Ire of Permit e { ) WORKERS'COMPENSATION DECLARATION 2004063DPW12/90 - MISCEL.LANEOU.S APPLICATION I hereby affirm that I have.a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING:.AND SAFETY DIVISION - � �F insure,or a certificate of.Wgikers'Compensation Insuram,:e, or a certified copy thereof (Sed. 3800, Lab.C.) - S Policy No. Company FOR APPLICANT TO FILL.IN BUILDING BUIL IN DDRESS ADDRESS ❑ Certified copy.is.hereby;furnished. X �(J �}'J�� LOCALITY ❑ Certified copy is filed with the county building inspection CITY ZIP ` department. cRoss sr: Date Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' CONST. O I COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP - HIGHWAY V NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS � by the permit is for one hundred dollars ($100) or less.) 0 r .r L certify that in the performance.of the work for which this rf �� A /� TEL NO. Lty permit is issued.'I shall not employ any person in any manner ADDRESS �j' so as to become subject to the Workers' Compensation Laws. O In OCCUPANCY GROUP tn ( DateJ1 Applicant S - _ CITY o ZIP l ply NOTICE TO APPLICANT: Ifng thi�icate �V� 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❑ ' revoked. No Spec.Knowl. El LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT El (LIST ITEMS BELOW) r I 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 effect. ame O uS1IIeSS ( Lic. Class PARKING• REO'D E= PROVIDED D License Number ( SPACES I t I i Contractor Date LIMITED TIME USE I ❑ I am exempt from the licensing requirements as I am a FROM: DATE TO. DATE licensed architect or a registered professional engineer acting in my professional capacity (Section 7051;Business SIZE OF NO.OF INSPECTOR'S (' I and Professions Code). EXISTING BLDG. STORIES SIGNATURE. Reg. PRESENT USE OF BUILDING Date FINAL APPROVAL — UUZ CQ_ Lic. or Re No. 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 ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044,11 PROPOSED USE OF BUILDING i Business and Professions Code). 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 state that the 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 the above-mentioned property for inspection p rposes. .' I I TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE s Signature of Permittee Date t ( WORKERS' COMPENSAHUN DECLAKA11UN1 " ""' y�pp (( 1—. ., !! /� pp�� yyf`� /� �J r r gyp, 20-0063DPVU?2/90 ir1154 LLAI��VL/y Ale• CAVAN 1UN 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.p Policy No. Company FOR APPLICANT TO FILL IN BUILDING .• BUILDING ADDRESS ADDRESS kms. i ❑ Certified copy,is hereby;furnished. - X ,�' Locnury ❑ Certified copy is filed with the county building inspection CITY zIP t department. CROSS ST. Date - Applicant - SIZE OF LOT NO.OF BLOGS.NOW ON LOT DISTRICT NO. GROUP TYPEPROCESSED BY CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' TRACT BOCK LOT NO. t I COMPENSATION INSURANCE MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL. USE ZONE SPECIAL CONDITIONS - by the permit is for one hundred dollars ($100) or less.) -scterf}7 e2 TEL NO. L certify that in the perforrriance.of the work for which this � �- permit is issued;I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. ADDRESS Z � �� OCCUPANCY GROUP , I Date Applicant CA IP NOTICE TO APPLICANT: If; after making this Certificate OCCUPANT LOAD of Exemption, you should become subject to the WorkersAPPLICATION FOR Compensation provisions of theLaborCode.you must forthwith EXIT HARDWARE: i comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Know!. ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) Cl A i ( 9(commencing with Section 7000)of Division 3 of the Business No.OF ExlTs a and Professions Code,and my license is in full force and effect. .. Name o ustness PARKING• REO'D O PROVIDED D License Number Lic. Class SPACES r t I I Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am a DATE DATE FROM: TO: licensed architect or a registered professional engineer n ;. acting in my professional capacity(Section 7051,Business SIZE OF OF EXISTING BLDG. S ORIF§ INSPECTOR'S and Professions Code). �y SIGNATURE. Lic. or Reg. No. - Date PRESENT USE OF BUILDING FINAL APPROVAL ��V Z V 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,Y PROPOSED USE OF BUILDING Qc.All•-,' � Business and Professions Code). t I 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 t (Sec. 3097, Civ. C.). PROPOSED MAX.OCC. I Lender's Name - APPAr+(PRINT) - TEL NO. Lender's Address ADDRESS C 1 I certify that I have read this application and state that the �rI M above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representiv. .of this County to enter upon ISSUANCE FEE the above-mentioned pro rty for ins ection purposes. - - TOTAL FEE 7. SEE REVERSE FOR EXPLANATORY LANGUAGE a Sign re of erm'tee Date , L I WORKERS' COMPENSATION DECLARATION 76M444 t CE 8751„ 84, M ISCELLANEOUIS APPLICATION 1/7 I here» affirm that I have a certificate of consent to self COUNTY OF LOS .-ANGELES BUILDING AND SAFETY DIVISION insure. or or a certificate of�Varkers'Compensation Insurance.or a certif;P¢copy t7nereof(Sec. 3800.Lab. C.). Policy No. _CompanyFOR APPLICANT TO F!LL IN BUILDING / J ❑ ADDRESS xv 1 .�/ Certified copy is hereby furnished. p BUILDING A AD DR ESS �' LOCALITY 'q t Certified copy is filed with the count buildinL inspection LOCALITY NEAREST G d ❑ department. Temple City CROSS ST. Date Applicant NEAREST DISTR IGT N G UP TYPE �� CESSED BY C , /�� / ( ST. CERTIFICATE OF EXEMPTION FROM O\ FRO '�ORhERS ROSS ST.LEGAL CON G 'I C_ON"IPENSATION INSURANCE ' DESCPIPT!ON LOT NO. �BLOCK i'�Av .1—Ay ' STATE MAJOR SECOND LOCAL INC, OF SLOGS. iThls section need not he completed If the work involved I TRACT NGW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars 6100) Or less.) I USE OF f ! SICE OF LOT. EXISTING BLDG. , I certify that in the ocrtnr;nance v[ :!le ,cor's: or 'hick this 77 4-4,4-1 -FO M�) - Permit is issued. I stall not employ ani' ne-son :n any manner OWNER -� 4- SO amu `l I so as to become suhiect ;o the '',�'orkers ':untpensation Laws NAIL r �-7 OCCUPa,NC`' GROUP = ADOR �� 1 Date Applicant — - 'EL. ^ — NOTICE TO APPLICANT: If. a ( Q i-e- makirc :!us t irate I>t gj C!T-r No. OCCUPANT AC Exemption. you ;ilould become suitiecr -o flu \%!-:s-:s I _. Compensalion ottr.inions vt the Labor Code. VOu Must torch- aP L!CATiCN SJR .,'(IT HARC1:�4>F�: I 1k'itll coinniv pith <nCl1 provision, --his 'ermir shall be I-RAILER JSE !J GEOLOGY :NSP-CT.!ON — •�o SL'eC deemed -eked. - �• { - I J . - LICENSED lON1RACTORS DL-CLARAlIO` occ'JPANCY IN SPECTIONgg Panic Dev res I hereby ifirm -hat l am Iicensed undo;prcvisions of Chapter SAFETY PERMIT (LIST ITEMS BE LO:'!) t 9 (commencing wv!th Section '000) of Dixisfon 3 of the Btisl- NO. OF EXITS ness and Professions Code. and rn% license is :,it -till force and � effect. PARKING REO O PRCVID ED ,c / SP4CE5 L License \umber Lic. Cass _ �Z LIMITED TIME USE Contractor Date_ oATE S N -- ATE W Z l lm exempt r-,om the icensinz reeuirenients as l silt .s m t licensed architect or a re'^istered pmtessional engineer SIZE OF NO. OFINSPECTOR'S '_ Z actin ;n -iiv pr(`tBus- EXISTING BLDG. 70R!F5 SIGN TURE mess;Ind i'rOtesslctls CJde). PRESENT USE OF BUILDING IFINAL APPROVAL Lie. or Re^_. I HOME `J"NI.R-111_.ILDER DIEGLARAF!O\ NO. OF EXISTING BUILDINGS � ON LOT AND USE I hereby aft rm -hat 1 :un -tempt from ;he Contractor's I License Law Cor the following reason (Section7031.f. Busi- ness and Profession$Code): NO. PARKING 1, as owner Of the propert}', will do ;he work and the SPACES PROVIDED structure is not intended or offered for ;Ae (Section 1 7044. Business and Professions Code). CONSTRUCTION LENDING AGI-N "1 PROPOSED USE OF BUILDING I I herebv affirm that there is a construction lending a--en'cv for the performance of the N.vork for which ,Itis permit. iso issued(Sec. 3097.Civ. C.). _41i ; Lender's Name ,-:' PROPOSED MAX. OCC. IV,1 Lender's address ' '71 t PERMIT FEE I certify that I have read this application and state that the 25'dd r 1 f above information is correct. I aLree to comply with all County ISSUANCE FEE ordinances and S • e laws relating to building construction, and lie eby au e represents yes of this County tor', TOTAL FEE ! upon the abovL n ned pro n' r ins ytion rpos 25.�O '. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE ) ;•; Sienatur of P mittee Date 1 .. WORKERS'COMPEN SATION.DEC LARATION. .,-76M444 CE 875 (2-80)- NBISCELLANEOIJS APPL.ICATIO.N I herebyr affirm that i have certificate of consent to self :COUNTY-OF LOS ANGELES' BUILDING AND SAFETY DIVISION . insure, or a certificate of Workers' rs'Compensation Insurance,or 'I aLtertified copy thereof(Sec:3800, Lab.C.) Policy No. FOR AP Company _ _ ADDLRESS PLICANTTO FILL. / ❑'Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY ❑ - Certified'copy is filed with the county building inspection NEAREST. .department. LOCALITY ` _ �, _ '' - cRoss sr. ' Date 'Applicant NEARESSS T "DISTRI/C/ITNO.: GR�(/()QUyP TYPE PRO EDBY . _ CRO LEGAL 'In a .. CV V Y C� CONST CERTIFICATE OF EXEMPTION FROM WORKERS'. DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE MAP r+'�r wAv srwrE Mw�oR SEC D LOCAL } NO. (CIRCLE) a NO. OF BLDGS. (This section need.:not be completed if the Work involved TR'A'CT NOW ON LOT USE ZONE SPECIAL CONDITIONS OU by the permit As'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 Q permit is issued, I shall'not employ'any person'in.any manner OWNEg` �. U so as.to become subject to the.Workers' Compensation Laws. 6�2MAIL ^J OCCUPANCY GROUP- ADDRESS '� d Date Applicant N TEL _ z 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: Compensation provisions of the Labor Code, you must forth- with comply with .such proyisions';or this .permit shall. be TRAILER'USE GEOLOGY INSPECTION deemed'revoked. ❑ No Spec. Knowl. a LICENSED CONTRACTORS DECLARATION occuPArvcv INSPECTION Devices sPEcrloN❑ 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 Busl ness and Professions Code, and my license is in full force and . effect. PARKING 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 acting:in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S GNATURE iness and Professions Code). .. - FIN'A'L APPROVAL PRESENT USE OF BUILDING' Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION ON of LOT AND UANDEXIUNG Bu7LolrvGs ON SE 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 El I, as owner of the property; will do the'work and the `Q S O A structure is not intended or offered for sale (Section 7,044, Business and"Professions Code ' PROPOSED USE OF BUILDING CONSTRUCTION LENDING-AGENCY 0 8 8' I hereby affirm that there is .a construction lending agency 1 rv' a e o 00.0 o for the performance of the work for which this permit' is issued(Sec. 3097,Civ.C.). U 0 3.03 8 6 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 here y authorize'representatives of this County to enter upon' a above-mentione property,for inspection purposes.. 'SEE REVERSE FOR EXPLANATORY LANGUAGE d fro ignature of Permittee Date WC RKEIv§ COMPENSATION DECLARATION CE 875(1 1-84) MISCELLANEOUS APPLICATION i.,. 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 .Q ADDRESS Certified copy is hereby furnished. BUILDING T ADDRESS9415 E. Las Tunas Drive LOCALITY El Certified copy is filed with the county building inspection LOCALITY. NEAREST department. Temple City CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE O ESSED BY CROSS ST. Oak 70& 0 CONST •, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP//�•• p HIGHWAY rvo./=/{,.�•1�� (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. section SBCOn 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 o permit is issued,I shall not employ any person in any manner OWNER Dnntsnn =' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADDRESS - U Date Applicant ,,, TEL. OCCUPANT LOAD "- NOTICE TO APPLICANT: If, after making this Certificate of CITYTelnl2le City ND. g18 285-7878 � 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 9 (commencing with Section 7000) of Division 3 of the BUSY SAFETY PERMIT LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKING REq'D O PROVIDED D SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE 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 IG ATURE inessand Professions Code). ;n FINAL APPROVAL . PRESENT USE OF BUILDING V (/a I ' Lic.or Reg.No. Date vv L/ 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 I I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section -25 6 711 A 7044,Business and Professions Code). / CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ,� •o 0 0 8 8 I hereby affirm that there is a construction lending agency CO\AA V�A 11, (, �F e o 0 0 0 o a ^, for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). \ 1s10, 1 6-86 Lender's Name � • PROPOSED MAX. OCC. Lender's Address I cel0�fy 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 ereby authorize re ntatives of this County to enter .TOTAL FEE ` - upo�n fhe�bov -menti e pr perty for insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P e�IhjDate I WORKERS!,COMPENSATION DECLARATION 76M444 ";1— CE 875(11-84) M ISCELLANEOUS'APPLICATION I r, affirm I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or•I certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS SC ADDRESS J FICertified copy is hereby furnished. BUILDIN S LPA �/N� �Q ADDRESS /J LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY W NEAREST department. 7 �M, IN CROSS ST. Date Applicant NEAREST `y' DISTRICT NO. G UP YPEPO ESSEDBY CROSS STK. O AI` 3IT CONST. 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 NO.W ON LOT USE ZONESPECIAL 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 p J ,� 1 i permit is issued,3 shall not employ any person in any manner OWNER i 1� ��1�i 1�+ /vl y so as tobecome subject to the Workers' Compensation Laws. OCCUPANCY GROUP ADDRMAIL ES'Y� ,�[/ V�� t ✓ • O Date Applicant I , NOTICE TO APPLICANT: If, after making this Certificate of CITY l„ M no OCCUPANT LOAD N 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices EJ 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 , ) /� N ..[� � t ne effect. IV rC ,v` r PARKING SPACES REQ'D PROVIDED License Number Lic. Class L=cAL" LIMITED TIME USE Contractor Date w DATE DATE 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 SIGNATU E inessandProfessionsCode). FINAL APPROVAL PRESENT USE OF BUILDING I VS SSS - c Lic.or Reg.No. Date rVVHOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ` ON LOT AND USE •" II a0. EE 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 q{ // SPACES PROVIDED - 0000 �L� li `�` 1�•��9 1, as owner of the property, will do the work and the or' structure is not intended or offered for sale (Section 7_c 29 1 AM10'.59 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY �14OPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency 6! l for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). r Lender's Name t PROPOSED MAX. OCC. Lender's Address PERMIT FEE r 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 au a representatives of this County to enter TOTAL, FEE on the ab( men ed property for inspection purposes. T 1 L '♦�I,, SIyE REVERSE FOR EXPLANATORY LANGUAGE Signat e of P rmittee Date