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Home My Public Portal About9424 LAS TUNAS DR_Miscellaneous__ WORKERS'-COMPENSATION'DECLARATION 76M444 CE 875 (2-80) MISCELLANEOUS APPLICATION ' 1 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,N0. Company. FOR APPLICANT TO FILL IN BUILDINGqy �/ ADDRESS /lAS , ❑ Certified Copy is hereby furnished. j7uL97NG /� ��// �+ /- �•� A'/ Loc ALIT-i �/j.� T /nI O. 7- ADDRESS-14-- ' G L,AS /\.�MA:S M Pg 1-7 lel T- ,. ... Certified copy is filed with the county building inspection. NEAREST department. ocALITY 7r'EHP4e C/7-V CROSS ST. Date Applicant AREST ��r ^ DISTRICT NO. GR UP TYPE PRO SSED BY CROSS ST. �:..A&'. AVE' �`D CONST. CERTIFICATE OF"EXEMPTION FROM WORKERS LEGAL DESCRIPTION LOT NO. BLOCK MAP HIGHWAY COMPENSATION INSURANCE No. 90 (CIRCLE) STATE MAJOR sECO LOCAL a, (This. 'section need not be completed if the.work involved _ NO. OF'B LDGS. O l P. TRACT NOW ON LOT � USE'ZONE SPECIAL CONDITIONS by the permit is for.one=.hundred dollazs,'($100) or less.) USE OF +, SIZE OF LOT - EXISTING BLDG. v c' I certify that w in the-performance of the work for which this' 0 permit is.issued, I shall not employ any person in any manner NER. LA u U so as to become subject to the Workers'Compensation Laws. IL" OCCUPANCY GROUP IL ADDRESS 9;+_6337 0J. F/eATI:S ply• a Date Applicant N. TEL. Z NOTICE TO APPLICANT: If,,after making this Certificate of CITY 7�/ E C.jrV NO. S/t/Ig 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 IN , deemed revoked. ❑ No Spec."Knowl. ❑ LICENSED CONTRACTORS DECLARATION occuPwrvcY INSPECTION Panic Devices ❑ I hereby affirm that I-am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS ❑ 9 (ccommencing 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 D PROVIDED. �. License Number Lia Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ElI`am exempt from the licensing requirements as, I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting IR my professional capacity' (Section 7051, BUS-' EXISTING BLDG. STORIES GNATURE inessand Professions Code). FINAL APPROVAL . ^J ESENT USE OF.BUILDING ., . Lic.or Reg.No. Date —♦ VVVVVV LA uNO/e}Y HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS ON LOT AND USE Ihereby affirm that, I- am exempt from' the Contractor's 45 2 8;A License Law for the following reason (Section 7031.5, Busi-, p ness and,Professions`CodeNO. PARKING):'. SPACES PROVIDED # O.0:0 O 85V 0 0 0 0 0 0 0 N ❑ I, as'owner of the property, will do the work.and the z structure is not intended or offered for sale (Section 7044, Business and,Professions Code). POSE _ D USE OF BUILDING '0 2:14 8 5 . - CONSTRUCTION LENDING AGENCY I. hereby affirm that .there is a construction lending agency 4•A11ACl40R for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). ' Lender's Name PROPOSED MAX:.00C.: Lender's Address - r _ PERMIT.FEE I.certify that I have read this application and state that the `above information is correct: 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 upon he above-mentioned property for inspect' purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE .t, Signature' ermitte ate' WOIIKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L L A/y N E O U S APPLICATION CE 875 1 sure, o affirm that I have a certificate of consent nc 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. BUILDING LOCALITY DDRESS Certified copy is filed with the county building inspection LOCALITY ✓ / NEAREST department. CROSS ST. Date Applicant NEAREST DISTCT G TYPE PRO! SSED BY CROSS ST. /� CONST., / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U \VJ COMPENSATION INSURANCE DEscRIPT1oN LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECO D 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 ($100) or less.) USE OF yZE OF LOT EXISTING BLDG. - I certify that in the performance of the work for which this CZ q o permit is issued, I shall not employ any person in any manner OWNERLAY c �j \4 _ y so as to become subject to the Workers' Compensation Laws. AIL ''C OCCUPANCY GROUP - o LDRSS I rR TU5 R, - >. t \ \ U Date Applicant - ,,, TEL' OCCUPANT LOAD o_ NOTICE TO APPLICANT: If, after making this Certificate of No. '1 cn 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 USEGEOLOGY INSPECTION ❑ ❑ E] No Spec. Know]. deemed revoked. occuPANCY INSPECT1oN Panic Devices LICENSED CONTRACTORS DECLARATION 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 �M PARKING effect. SPACES REQ�D O PROVIDED D License Number Lic. ClassW Al LIMITED TIME USE Contractor Date IL ( DATE DATE ❑ I am exempt from the licensing requirements as I am a — L IIV FROM: To: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXI TING BLDG. STORIES SI NATURE iness and Professions Code). FINAL APPROVAL -14 PRESENT USE OF BUILDING Lic.or Reg.No. Date N R HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 2 0 3 0.8 A ON LOT AND USE I hereby affirm that I am exempt from the Contractor's #.e 0,0 e r;6 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED o,o o;o'o'o o z I, as owner of the property, will do the work and the , structure is not intended or offered for sale (Section 0 7.29-!-88 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency LA YIV,99 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. /1 Lender's Address PERMIT FEE QD I certify that I have read this application and state that the IVl" above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, • hereby authorize representatives f Ibis County to enter TOTAL. FEE , u on e abov - ention perty spection purposes. �SEE-REVERSE FOR EXPLANATORY LANGUAGE ito of { ate �/,Y