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HomeMy Public PortalAbout9527 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 4) M I SC E L LA N EO U S APPLICATION CE 875 (11-8 I hereby affirm that T 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.Q. Policy No. Company FOR APP LICANTTO FILL IN ABUILDING DDRESS 'L Certified copy is hereby furnished. BUILDINGLOCALITY ADDRESS G� Certified copy is filed wiih the county building inspection LOCALITYNEAREST department. P CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY PaiCERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr.LEGAL P.O eiD p coNsr. � O COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This section perm OF BLDGS need not be completed if the work involved TRACT NONOW. ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USOF BLDG.OF SIZE OF LOT /) 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 L- OG P e cw cD so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP —� O Date Applicant ADDRESS W NOTICE TO APPLICANT: If, after making this Certificate of CITYgCJZSZIF 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: Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ 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 RE SPACES Q D D PROVIDED D License Number Lie. Class ) � LIMITED TIME USE �/ Contractor Date •/ 0 / v� 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 INSPE CTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL / _2� PRESENT USE OF BUILDING IO J 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 �"1 License Law for the following reason (Section 7031.5, Busi- ness usi ness 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,Business and Professions Code). CONSTRUCTION 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(See. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address I certify 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, DZ) and hereby authorize representatives of this County to enter TOTAL FEE upon the above- o el operty for inspection purposes Ci SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ure of ermittee ate i WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION _ 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 II a certified copy thereof(Sec. 3800.Lab.C.). BUILDING -7 J Policy No. Company FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. BUILD ING ©� LOCALITY ADDRESS GSa� 7 I Certified copy is filed with the county building inspection LOCALITYTNEAREST department. emple City CVOSS ST. Date .applicant NEAREST T I OISTRICT NO. GROUP TYPE ,y� CESSED BY CROSS ST. yQ,r(\ ,Q_ l:.l} CONST CERTIFICATE OF EXEMPTION FROM l_Y ERS LEGAL o �/ 1 COMPENSATION IN t OESCRIPTI ON LOT X10. !9LO CK IMP.P HIGHWAY ' No. (CIRCLE) STATE MAJOR SECOND LOCAL NC. OF 13L GS. (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 (5100) or less.) USE o= i SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which -his permit is issued. I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. j OCCUPANCY GROUP MAIL ! - ADDRESS ('71_0 - Dz _ ! Date applicant Mo Q'3 r t - TEL. OCCUPANT LOAD NOTICE O APPLICANT: lf, after making this Certificate of XI CITY t No. - Exemption. you should become subject to the Workers' Compensation provisions of the Labor Code. you must forth_ APPLICATION FOR I XIT .AR DINAR E: M with comply with such provisions or this permit shall be TRAILER USE GECLOGY INSPECTION 1-1 I �� CCp( ����WI deemed revoked. t — ` OCCUPANCY INSPECTICN$$ Panic Devices LICENSED CONTRACTORS DECLARATION I � I hereby affirm that I am licensed under provisions of Chapter iSAFETY 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 /D/ ~ !�f/ PA, K?NG effect. N SP:G CSS REO•D I PROVIDED I Il – I License Number Lic. Class i LIMITED TIME USE I Contractor Date TATE GATE FRC.— requirement! ZC.N: TO: 1 am exempt from the licensing requirements as i am a licensed architect or a registered professional engineer �sIZE OF No. of NSPECTOR S i acting in my professional capacity (Section 7105i. Bus- I EXISTING BLDG. + I 5 �l STOReES I S GN ATURE 1 inessandProfessionsCode)• f FINAL APPROVAL PRESENT USE OF BUILDING v Lic.or Ree.No. Date \ – i t HONIE O«'1ER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's FEE I License Law for.the following reason (Section 7031.5. Busi- ness and Professions Code): No. PARKING WA-00011 101 19t SPACES PROVIDED •��a• 1, as owner of the property. will do the work and the espy structure is not intended or offered for sale (Section i 7044.Business and Professions Code). CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDINGsd es I herebv affirm that there is a construction lending agency 1 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 i I certify that i have read this application and state that the PERMIT FEE 25,00 above information is correct. I 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 25.00 ' I .upon the above-mentioned property for inspectionpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date r s