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HomeMy Public PortalAbout9475 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION s ' + CE 875 I hereby a &rtiat I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certficicC ate of Workers' ompensation Insurance,e,or a certified co y there f(Sec. 3800,Lab.C). I ,� Policy No. ompany • ��— 41 FOR APPLICANT TO FI LL IN BUILDING (y� ADDRESS / Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS F. Los4unqs or Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRIC�==NNN O. G U TYPE PR ESSE BY CROSS ST. /"j(/ CONST.. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (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 ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER .ae s� so as to become subject to the Workers' Compensation Laws. MAIL` O L W(5 ® OCCUPANCY GROUP �� o ADDRESS 1-- Date Applicant C.5 NOTICE TO APPLICANT: If, after making this Certificate of CITY NOcaL . (g'— ?6_2 OCCUPANT LOAD N Exemption, you should become subject to the Workers' Z APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIOPanic D@VICe$ N I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM [J (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 /L� effect. r ` SPACES PARKING REQD = I PROVIDED License Number Lic. Class FW1 c he. ' LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineerSIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL —:2 PRESENT USE OF BUILDING ..., Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION = NO. OF EXISTING BUILDINGS ^ll FEE 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 i{i71 €_=iIII J. ness and Professions Code): NO. PARKING ElI, as owner of the property, will do the work and the SPACES PROVIDED V= 9 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 o . for the performance of the work for which this permit is i issued(Sec. 3097,Civ.C.). I Lender's Name PROPOSED MAX. OCC. Lender's Address O 0 PERMIT FEE 1� 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 he b authoriz representatives of this County to enter TOTAL FEE u on ove- Toned propert or inspection purposes. .41 SEE REVERSE FOR EXPLANATORY LANGUAGE If Sign t re of Permittee Date WORKERS'COMPENSATION DECLARATION. CE 8754(2-80) MISCELLANEOUS A P tlr L I G A T I O N I hereby affirm that I have a cerz�€mate 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 -APPLICANT APPLICANT TO FILL IN BUILDING, a� ADDRESS ❑ Certified copy is'hereby furnished. /G LOCALITY y ❑ - - ADDRESS �L77. /r•� -�/ Certified copy is filed with the county building inspection. �� �- NEAREST ocALITr department. cRoss sr:" Date Applicant NEAREST .Q DISTRICT NO. G OUP TYPEPROCESSED BY • CROSS ST. G, _ - - y CONST - CERTIFICATE OF EXEMPTION FROM WORKERS'. LEGAL DESCRIPTION LOT NO. BLOCK IHIGHWAY. • } COMPENSATION INSURANCEMAP : _. h o. (CIRCLE) STATE'M AlOR'SECOND LOCAL O NO..OF BLDGS., (This-'section need not be completed-if the work, involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE V / cc ' SIZE 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 iri any manner 4.QIWNER U so as to become subject to'the Workers' Compensation Laws. MAIL ��rr•�� i f �Os OCCUPANCY GROUP y UJ ADDRESS)©&4s ,/V. 1 e,4>c � / GAS N' Date ' Applicant NOTICE TO APPLICANT: If;after making this Certificate of CITY.A1j/91r�7, rvoL'.7/ _� Z-��j�� OCCUPANT LOAD z Exemption, you should become subject to the WorkersAPPLICATION.FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit Shall be TRAILER USE E GEOLOGY INSPECTION N ❑ deemed revoked. o Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ Fes.,.1 Ihereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (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 -e ,II:_a :: PARKIN92 G effectt . SPACES REO'D C� PR OC/ID'ESY i •• License Number Lic.Class LIMITED TIME USE Contractor Datev - • '/� 4 �m %\JDATE DATE r ElYVV C. to o� FROM' TO: I am exempt from the licensing requirements as,l 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 / SIGNATURE mess and Professions Code). PRESENT USE OF BUILDING r. FINAL�APPROVAL ? Lic.or Reg.No. Date— HO ME ateHOME 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- NO. PARKING ,- ness and Professions Code):' _ SPACES PROVIDED - ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code).' 61 n PROPOSED USE OF BUILDING Y - CONSTRUCTION LENDING AGENCY' 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. 0CC. Lender's Address PERMIT FEE DtCJ I certify that I have read this application and state that the above information is correct.;l 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 ✓j on e above-me tioned prop rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date