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HomeMy Public PortalAbout9535 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS2• ) APPLICATION P P L I C®TIO N,_ CE 875 (11-84 I h o affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'rs'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). I Policy No. Company FOR APPLICANT TO FILL IN BUILDING •r� r ADDRESS Certified copy is hereby furnished. BUILDING L ) ADDRESS ��J (J G LOCALITY i C DCertified copy is filed with the county building inspection OCALITYj. NEAREST department. e�2 ceoss sr. +fes Date - Applicant EAREST DISTRICT NO. GrUR TYPE PROCESSED BY CROSS ST. Q /� CONST,/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL , 1J `J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. No. (CIRCLE) STATE MAJOR SE OND LOCAL 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 SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this permit is issued, I shall not employ any person n any manner OWNER o so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP �� � DDRESS , �. d �dd y��O Date Applicant cr c t3 TEL. gJ`j �'b£;n� LO NOTICE TO APPLICANT: If, after making this Certificate of CITY F� No. g _}�gy OCCUPANT LOAD yy 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 GEOL GY INSPECTION ❑ N deemed revoked. o Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 REQ'D D PROVIDED . SPACES 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 engineerIZE of ND. OF IN PECTOR•S acting in my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES IGNATURE iness and Professions Code). c--- FINAL APPROVAL 7 PRESENT USE OF BUILDING �S,E� Lic.or Reg.No. Date / HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O o 0 0 00 o z ON LOT AND USE I hereby affirm that I am exempt.from the Contractor's 0 1, 1 5-8 8 License Law for the following reason (Section 7031.5, Busi- 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(Sec. 3097,Civ.C.). 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, and hereby authorize rep ntatives f this County to enter TOTAL FEE on above-mentioned r perty f r inspectio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) W SC E L LA I tl G OU SAPPLICATION 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 a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Com anBUILDING FOR APPLICANT TO FILL IN E' ADDRESS ❑ Certified copy is hereby furnished. BUILDING ADDRESS /� LocwLlry L ❑ Certified copy is filed with the county building inspection ��� NEAREsr department. LocwLIT CROSS ST. Date Applicant NEAREST I DISTRICT NO. G UP TY E PR CESSED BY CROSS ST. /P! CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP /� HIGHWAY NO. F BLDGS. NO. �J (c Rc,e) STATE MAJOR SECOND LOCAL � (This section need not be completed if the Work involved TRACT NOWOON LOT USE ZONE .SP CIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE of U SIZE OF LOT EXISTING BLDG. IM I certify that in the performance of the work for which this Q permit is issued, I shall not employ any person in•any manner OWNER ° 0 so as.to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP /�A/�r W ADDRESS _ O- Date Applicant LG� r) TEL. . OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of clrY NO. Exemption, you should become subject to the Workers' APPLICATION FORj EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this-permit shall be TRAILER USE GEOLOGY INSPECTION 0 No Spec.IKnowl. ❑ dyemed revoked. LICENSED CONTRACTORS DECLARATION occuvwrvcY INSPECTION Panic Devices ❑ l:�hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS ❑ 91(commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and ' PARKING effect. SPACES REO'D O PROVIDED License Number Lic.Class ��JJ LIMITED TIME USE Contractor Date DATE DATE FROM:. - TO: ❑ I am exempt from the licensing requirements as I am a IN licensed- architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S •acting In my professional capacity.(Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE IneSS and PiOfeSSlOr1$Code). PRESENT USE OF BUILDING FINAL APPROVAL s`/yam Lic.or Reg.No. Date f HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE 'Z 1 75,5 A I hereby affirm that I am exempt from the Contractor's f License Law for the following reason (Section 7031:5, Busi- ness and Professions Code): NO. PARKINGSPACES PROVIDED. - -O°O,O O OIO O ❑ 1, as owner of the property, will-do the work and the structure is not intended or offered for sale'(Section O 6,0'6—8 3J 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY j� � I hereby affirm that there is a construction lending agency .CJ 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 ISSUANCE Fee i ordinances and State laws relating-to building construction, TOTAL FEE S and hereby authorize representatives of this County to enter C upo��' above-` oned property riinspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS' CONIPENSNHON DECLARATION0-0,)W0PVY I: DU MISCELLANEOUS APPLICATION ?' I hereby affirm that I hate a ccitificale of consent 111 Sell COLIN'Il' OF I.OS ANGFIA-S BUILDING AND SAFETY DIVISION I� i insure,or a certificate of Workers' Compensation Insurance. nl a certified copy thereof (Sec. 3800. Lah. C.) _ j Policy No._ _ Company FOR APPLICANT TO FILL IN EUILDING s✓' / BUILDING ADDRESS ADDRESS El Certified Copy Is hereby furnished. x _ �_$� 3.r Cls 70A,-PV I.00ALITY E] Certified copy is hied will) elle 001,11 t) htllldlllL IIISpCCtloll CITY i ZIP 7^� .��d J department. 1;1 "EAREST 1'E / 7 CROSS ST. Applicant SIZE OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO. ;FP TYPE SSED BY CONST' t" CERTIFICAI 01 EXEMPTION FROM WORKI'.RS TRACT BLOCK LOT No. —�O� CONIPENSAIION INSURANCE: MAF HIGHWAY L j .I NO.. ICIRCLEi STATE MAJOR SECOND LOCAL (This Section need not he compleled if the murk in%oI%cd ASSESSOR MAP BOOK PAGE PARCEL 1))' (he permit IS for 011e humdred dollars (,..,100) 111 less.) USE ZONE SPECIAL CONDITIONS U I certify that in the performance of the work fpr which this OW > TEL NO. Permit is issued. 1 shall not employ an)' person in :Iny planner so as to become subject to the Worker;' Cowpen,amnn L;nas. ADDI``� / OCCUPANCY GROUP i Date Applicant c Y ZIP " NOTICE TO APPLICANT: If, after making this Certificate _ OCCUPANT LOAD of Exemption• you should become subject to the Workers APPLICATION FOR Compensation precisions of the Labor Code.you must lOitImith EXIT HARDWARE: comply with slick provisions or this plimit shall be Lleelllell TRAILER USE GEOLOGY INSPECTION�_I No Spec.Knowl. ❑ revoked. OCCUPANCY INSPECTIONN Panic Devices LICENSED CONTRACTORS DE:CLAR.ml)N _ = I hereby affirm that I all licensed Under prOVISlOiIS 111 (IhIplef SAFETY PERMIT O 1LIST ITEMS BELOW) a -`I 9(commencing with Section 7000)of DIVision 3 of the BLISIneSS NO.OF EXITS and Professions Code.and my license is In full force and effect. PARKING• REO'D [=71 PROVIDED D License Number Lie. Class Lll�7 _PACES Contlactor Date LIMITED TIME USE j e DATE DATE ElI alit exempt from the licensing requirements as I alit a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting Ill Illy professional Capacity (Section 701 1, Business , _ SIGNATURE ti f EX IS rING BLDG. .�iORIr.S and Pr0IcSSiOIIS COLIC). — ! LIC. Or Reg. No. - 1)a(e PRESENT USE OF BUILDING FINAL APPROVAL ..©� .. IICOE OWNER-BUILDER DI'A LARAIION NO.OF I:XISI INC,BUILDINGS - I ON LOT AND USE 1 hereby affirm that I am exempt from the Contractor's License � ID Law for the following reason (Section 70315. Business and — -- Professions (Ode): NO.PARKING v j�I. as rnvner of (lie pmpCrl\', will do SPACES PROVIDED t;Il Ltllrk and the Sll LICtllIC IS not intended lir Of1121'ed 101 Sall'(Seel loll 704.1 PROPOSED USE OF BUILDING �a Business and Professions Code). -.--- - CONSTRUCTION LENDING AGENCY hereby affirm that there is a conslruction ar ICndplg agency fo - _ t the performance of the work for which this permit Is Issued PROPOSED MAX.OCC. I (Sec. 3097,('iv. C.). Lender's Name '- ._. -. APPLICANT IPHI!JI) TEL NO. X @0U,,t-A-P ✓��� 1� Lender's Address .__-_. - ADDRESS I certify that I have read this application and state (hal the above information is correct. I agree to comply kith all County PERMIT FEE ordinances and State laws relating to building construction,and s hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. TOTAL FEE � I ' .� X SIE. REVERSE FOR EXPLANATORY LANGUAGE '; Signature of Kerinittee Dale ORKERS'COMPENSATIONDECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION � CE 875 _ 1 hereby affirm that I have a certificate of consent 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.). ---�-- LJ Policy No. Company -- FOR APPLICANT TO FILL IN BUILDING X ADDRESS Certified copy is hereby furnished. p BUILDING Tu.N ADDRESS EN --��T LOCALITY I Certified copy is filed with the county building inspectionCALITY g LONEAREST department. G� L r ICRoss sr. Date Applicant _ NEARESTi DISTRICT NO. GROUP TYPE CESS ED BY CONST i CERTIFICATE OF E`CEMPTION FROM WORKERS' CROSS ST.LEGAL d� .a! ta-�sJ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HID Hw Av ND. (CIRCLE) STATE MAJOR SECOND 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 (SI00) or less.) USE OF SIZE OF LOT EXISTING L.G.B I certify that in the performance of the work for which :his ! — tis issued, I shall not employ eperson in any manner g OWNER so as so as to become subject to the Workers' Compensation LaLvs• g n OCCUPANCY GROUP MAIL — t Date applicant - NOTICE TO APPLICANT: If, after making t ' �his Certificate of g CITY ToL OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth �- APPLICATION F R EXIT HARDWARE: i with comply with such provisions or his, Permit ilial] be TRAILER USE j-1GEOLOGY INSPECTION No Spec. Knowl. deemed revoked. — JEl Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 1 hereby affirm that l am licensed under provisions of Ch tlteI SAFETY PERMIT LIST ITEMS BE ' 9 (commencing with Section 7000) of Division 3 of the 13usi- NO. OF EXITS ness and Professions Code. and mv_ license is in full force and effect. JLC.LJ PARKING REO D PROVIDED I! SPACES LL��JJ License Number Lie. Class LL LIMITED TIME USE Contractor Date -- _ DATE DATE [ am exempt Erom she licensing requirements as I jin a 9 I licensed architect or a registered professional engineer ,IZE OF - INSPECTOR'S Z Z =X 15 IN BLDG. � fyy SI ATURE acting in m}' professional caeacity ,.Section ;0 1. Lus- e��` � ye7 _ inessand Professions Codel. FINAL APPROVAL V LIC.or Reg. No. Date PRESENT USE OF 9UILDING _ I 144 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ��� ON LOT AND USE 'D I herebv affirm that i am exempt from the Contractor's License Law for the following reason (Section i 031.5, Busi- ness and Professions Code): V NO. PARKING f, as owner of :he property. will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I lterebv affirm that there is a construction lending agency for the performance of the work for which this perntit is issued(Sec. 3097,Civ.C.). .. Lender's Name PROPOSED MAX. OCC. Lender's Address I 25.00 I certify that I have read this application and State that the PERMIT FEE ,i above information is correct. I agree to comply with all County ISSUANCE FEE 1i" ordinances and State laws relating to.building construction. l and lterebv authorize represe atives of this County to enter TOTp1_ FEE 25.00 a, upo a ove menti ed perty for inspection purposes. I % ��� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P-rmittee Date 4�