The URL can be used to link to this page

Home My Public Portal About9521 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APLICATI®N I hereby affirm that I have a certificate of consent to self COUNTY-OF LOS ANGELES BUILDING AND SAFETY DIVISLOIN 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. uILD iNG LOCALITY ❑ �ADDRESS 5�0 [.� Certified copy is filed with the county building inspection NEAREST L department. CALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROC SSED BY CROSS ST. / CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALIIGHWAY COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK Mqp R(CIRCLE) C, . NO. ) STATE MAJOR SECOND LOCAL CL (This section need not be completed NO. OF BLDGS. if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q by the permit is for one hundred dollars ($100) or less.) U USE OF SIZE OF LOT EXISTING BLDG. cr 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 wrvER 7/ 7� l_ so.as to become subject to the Workers' Compensation Laws. AIL C/ OCCUPANCY GROUP w ADDRESS Date ApplicantTEL�1�U . OCCUPANT LOAD z NOTICE TO APPLICANT: If, after making this Certificate of CIr NOrvo Exemption, you should become subject to the Workers' AFOLICATION 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 0 No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) rvo. 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 PARKING. effect. SPACES •REO'D E= PROVIDED D Liense Number Lia Class LIMITED TIME USE Co'ntractor Date DATE D AT E •A 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 SIGNATURE iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION No.of E TING BUILDINGS ON.LOT AND USE - S 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 z 5`6 8 7 A )' SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section # o 0 0 0 40 7044, Business and Professions Code). ROPOSED USE OF BUILDING I ' O O O O`O O OZ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 08, 1 '7'—8 2 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 issuANe Fe ce ordinances and State laws relating to building construction, TO TALFEE and.hereby authorize represe fives of this County to enter .�p u the ab ve-mentio d ro t� for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature'of er t e Date WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (11-84) 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 atcertified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS I Certified copy is hereby furnished. BUILDING ` �,5, N, , `G LOCALITY I Certified copy is filed with the county building inspection LOCALITY, NEAREST department. CROSS ST. Date Applicant NEAREST j / � DISTRICT NO G UP TYPE PROCESSED BY CROSS ST. (�./, U� [)^ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL •�� ' COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY` NO. (CIRCLE) STATE MAJOR SE CO LOCAL NO. OF BLOGS. (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.) us5 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 y so as to become subject to the Workers' Compensation Laws. MAIL �� Y OCCUPANCY GROUP ADORES. S f �� ' Yom' O Date Applicant � TEL;g OCCUPANT LOAD LU NOTICE TO APPLICANT: If, after making this Certificate of CITY N . d —�f�� 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 ❑ deemed revoked. TRAILER USE EJ G% EOLOGY INSPECTION ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I Panic Devices ❑ 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 effect. PARKING SPACES REO'D D PROVIDED D 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- (STING BLDG. STORIES SIGNATURE iness and Professions Code). D� FINAL APPROVAL 1117 Lic.or Reg.No. Date PRESENT USE OF BUILDING .4 144 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 Oil a 6'A I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section #i 6`8 i8 it.g 9 In 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ,0 7, 1 4 8 8 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. 1113 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, Td erebythea authorize representatives of this County to enter TOTAL FEE ove-mentioned-pro rty for inspection purposes. ------777777 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date