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Home My Public Portal About9511 LAS TUNAS DR_Miscellaneous__ \1'ORKE:RS'CONIPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION W I hereby affirm that I'�io a crtificof consent to self - insure, or a certificate of Workers'Compensation CE 875 (11Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof ISec. 3800,Lab.C.). Policy No. __.__-___-_Company FOR APPLICANT TO FILL IN BUILDING ADDRESS a Certified copy Is hereby furnished. XX BUI ADDRLDINGESS ,S p LOCALITY L} C (1..1` ' a Certified copy is filed with the county building inspection LOCALITY 1 NEAREST department. XX eY►1 OI'C� O CROSS ST. Date _________Applicant --_.—_ NEAREST DISTRICT NO. GROUP TYPE P ESSED BY .. CROSS ST. CONST. CERTII ICATE OF EXEMPTION FROM WORKERS' LEGAL. o CONIPF.NSATION INSURANCE; DESCRIPTION LOT NO. BLOCi( MAP HIGHW A'V ND. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (this section need mol be completed If Ilia WOIk involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE OF : SIZE OF LOT EXISTING BLDG. O I certify.that in the performance of the work for which this Q !� permit is issued, I shall not employ any person in any manneMCI t.J gg -E. of buildingCev DE2 ml as to become stlhiect to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �� o C) APPlicant ADDRESS f Z Date --------- --- — ul NO:IICF TO APPLICANT`. If, after making this Certificate of cITY �� I ��f No a -�� OCCUPANT LOAD N 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. I.IC'I.NSED CONI RAC7ORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby afflrn that I ani licensed under provisions of Chapter SAFETY PERMIT EJ (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 ati r effect. X Name of business e PARKING REG D I PROVIDED �� SPACES License Number ____- Lic. Class_ LIMITED TIME USE Contractor. _ Dale— .__ DATE DATE FROM: TO:- I ani exempt from the licensing requirements as I am a ;; licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTO s acting In Illy professional capacity (Section.7051, Bus- EXISTING BLDG. STORIES 5 NAT RE iness and Professions Code). PRESENT USE OF BUILDING FtNA APPROVALJ_Zq,G>*/' Lic.or Reg. No,.-.. -----_-----_-_-- Date IIrI�1PP HOME: OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS If V I " ON LOT AND USE I hereby affirm that I ani exempt from the Contractor's ,� License Law for the following reason (Section 7031.5, Busi /) j ii=:i,it-M'" .i j. tress and Protesslons Code): NO. PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,13usiness and Professions Code). CONSIRUCHON 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 .issued(Sec. 3097,('iv.C.). Lender's Name PROPOSED MAR'OCC. Lender's Address- ---- - -__ - - PERMIT FEE. - I certify that .1 have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances an St a laws reE mg building construction, and hereby Ith ire repres tat' of this County to enter ' TOTAL FEE 25.00 upon the rt 0 'or inspection purposes. ." XX ,y�..X�jX (, ��GE REVERSE FOR EXPLANATORY LANGUAGE I ,<<oRI:ERS COMPENSATION DECLARATION CE 87e (t l-aa)4 MISCELLANEOUS APPLICATION .. ce ayl' f hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS .ANGELES BUILDING .AND SAFETY DIVISION insure, or a certificate of Rorkers'Compensation Insurance.or a certified copy thereof(Sec. 3800.Lab. C.I. Polic%, No. _Company ^FOR �.A�PP/LI�C�ANT TO F!LL IN gUILDI- ❑ Certified copy is hereby furnished. BUILDING V/ LOCALITY AD OR EEr �V 1 Certified cops' is tiled with the counts'building inspection LOCALITYNEAREST411, department. Temple City CROSS ST. Dare-Applicant NEAREST DISTR`C�N O� Gq�UP TYP GESSED BY CROSS ST. !Jl(` /[ CONS CERTIFICATE OF EXEMPTION FROM ',GRKERS, LEGAL F COMPENSATION IN SL R.,NCE � OESCRIPT:ON LOT NO, iBLC CK !�'-��W 0. (C..0 E) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not he completed if the %cork Involved i TRACT NOW ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars ISM or less.) USE OF I SIZE OF LOT I EXISTING BLDG, { I certify that in the nerro-mane,- of -Ire .vorC: _o: .chich --his ; permit is issued. I Shall not employ aril- ne-son ':n am manner OWNER red Atistc6d � so as to become subject to the l,orkers' ..rnpensation l.a t's. aA1L � 0CCUPANC'; :ROUP ADDREss PD&4 gC13 t ZD Date Applicant _ f _ NOTICE TO APPLiCANT:,if. :uter makms: :',,isCern b are u p C:Tr�(�� L��x 'oL ,9$'7-9' a OCCUPc.N- LOAC Exemption. %:ou ihould become :uu_iec; -o -1te %`,n e:s ` * - CF =X1 HARcl,iJA^ Compensation orc`:isions Of the Labor_.__,)d0. �'ou A must forth- 1 !CA 71 CN = � ^ 77t xvith coniviv %\iih such provision1 -. :his :-er?nit ihail be (-RAILED USE GEOLOGY :NSPECT'ON _ No scec. i�;l(-.�+V1, ! deemed :e\0'Keu. !] LIC L-NSED CONTRACTORS DECL.ARAj1ON OCCUPANCY INSPEC-IONgg Panic Devices ❑ I lterebv artirm ;flat I am licensed under erevisionsof C;iarter SAFETY PERMIT (LIST ITEMS SELOW) a f 9 Icommencm� svtth Section '000) of Division � of the Susi- No. of EXITS ness and P-ntessions Code. and itiv license is ;it ull force and �I I e2Lect. C� ��J PARKINGSPACES REDO PRCVIDED I m License Number Lic. Class LIMITED TIME USE N Contractor Date — 'DATE DA-E w ❑ Z To: I am ,xempt from the iicensine reau emenu as [ lm 1 T licensed architect or a :e`distered prniessional :nnineer SIZE OF NO, INSPECTOR'S 9 - SIG TURE z actrns in my prOtiticlU nal _1P:2::i i', ..�<iUn -I\�t Bus- —LISTING BLDG. STORI=S m iness lila 111-o essicns Code). •' J Lic.or Rei*- Nu. D.,r 'RESENT USE OF BUILDING FINAL APP VAL HOME OWM—R-13LILDER DEC'LARATIO'N NO. OF EXISTING BUILDINGS ON LOT AND USEr 11 '�I /'V/• i^;fit�,-r p 1 1 hereby affirm that 1 am exempt from the Contractors t License Lass' ter the fol.loscing reason (Section _03L.5. Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED ❑ L as owner of the property, will do the wort: and the strucntreIs not intended or offered for sale (Section i 7044. Business and Professions Code). CONSTRUCTION LENDING AGE.NC PROPOSED USE OF BUILDING 1 hereby affirm that there is a construction tending :wenev t for the performance of the work- for schich this permit is issued (Sec. 3097,Civ. C.). Lender's Name—_-- -- PROPOSED MAX. OCC. Lender's address I PERMIT FEE 25.00 I certify that l have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State lases relating to building construction, and herebv author e re resen tines of this County to enter TOTAL FEE 25.00 ' upon the above-.men of d p rtv for inspection pur se: SEE REVERSE FOR EXPLANATORY LANGUAGE l Sipnat re of P rm' tee Date