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HomeMy Public PortalAbout9554 LAS TUNAS DR_Miscellaneous__ I *0' ;RS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION CE 875 (11 841 hereby a irm that I have a certificate of consent to self ns ertifp1 a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a -copy thereof(See. 3800,Lab.C.). polic o. Company FOR APPLICANT TO FILL IN BUILDING A n ADDRESS Certified copy is hereby furnished. BUILDING .S" �� ADDRESS LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO,. G O P TYPE PROC SS D BY CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �0 COMPENSATION INSURANCE DESCRIPTION' LOT NO. BLOCK MAP. HIGHWAY rvo. (CIRCLE) STATE MAJOR SE CO 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 ($100) or less.) JUSE 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 in any manner OWNER oF LOG "L o so as to become subject to the Workers' Compensation Laws. MAIL �c, �e AA c OCCUPANCY-GF OUP �r\� CD D to Applicant ADDRESS ta V 7N 9\ . V L��l� U a pp LO NOTICE TO APPLICANT: If, after making this Certificate of CITY C TNEIL .94671 ,3 OCCUPANT LOAD 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (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 REgD PROVIDED License Number Lic. Class SPACES LIMITED TIME USE Contractor Date DATE DATE DI am exempt from the licensing requirements as I am a FROM` TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE y iness and Professions Code). FINAL APPROVAL / Lie.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO.OF EXISTING'BU ILDINGS 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 SPACES PROVIDED �2 0 8 a 5 A I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section # o o.o Ie 88 7044,Business and Professions Code). o o CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING `o .o:0 0 o z I hereby affirm that there is a construction lending agency 1-- P I Q l Q'"8 8 for the performance of the work for which this permit is L issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. l` Lender's Address QV a'1\ I certify that I have read this application and state that the PERMIT FEE \ above information' rrect.I agree to comply with all County ISSUANCE FEE Wordmanccs � ws relating to building construction,presentatives of this County to enter TOTAL FEEd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Urmittee .— Date WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (2-80) MISCELLANEOUS APPLICATION 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. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS ❑ Certified copy is filed with the county building',inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I '. COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP HIGHWAY it ry o. (CIRCLE) STATE MAJOR SECOND LOCAL O (This section need not ompleted if the Work involved TRACT NOW ON LOT USE ZONE�=_CONDITIONS U by the permit is' or onn NO. OF BLDG$. undyed dollars ($100) or less.) USE OF U.1 SIZE OF LOT EXISTING BLDG. K I certify that in the p formanc f the work for which this permit is issued, I shall qot empl y Vny person in any manner OWNER so as to become subject,to thertersi,COmpens�tion Laws. MAIL OCCUPANCY GROUP I 1- pp ori \�, ADDRESS Date A lican L. NOTICE TO APPLICANT: f, after-m ngi this Certificate of CITY NO.. OCCUPANT LOAD Exemption, you should tSecom su to;the `Workers' 202 Compensation provisions of the boi" ode, ypu must forth- APPLICATION FOR EXIT HARDWARE: W with comply with SUCK plOvlsl Or th15 rmtt shall be TRAILER USE GEOLOGY INSPFCTION deemed revoked. No Spec. Knowl. ❑ H LICENSED CONTRACTORS DECLARATION occuPAvcv INSPECTION Panic Devices ❑ I hereby 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 effect. PARKING SPACES REQ'D E= PROVIDED License Number Lic.Class J LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a, FROM T 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 PRESENT USE OF BUILDING 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 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING a 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). `C PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 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 o- 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, TOTAL FEE hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WOR";ERS'COMPENSATION DECLARATION CE 875(-11-54) 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 a certified copy thereof(Sec. 3800,Lab.C.). BILDING Policy No. Company FOR APPLICANT TO FI LL IN U ADDRESS J Certified copy is hereby furnished. BUILDESSING LOCALITY ADDR Certified copy is filed with the county building inspection A LOCALITY NEAREST department. CR oss sT. Date Applicant 'NEAREST ` DISTR TYPE PROCESSED Y j CROSS ST. JZ• /`}(' CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAONST. `(Jv COMPENSATION INSURANCE DESCRIPTL ION LOT NO. BLOCK MAP HIGHWAY NO.NO. F BLDG (CIRCLE) STATE MAJOR SEC LOCAL fp� (/�' (This section need not be completed if the work involved TRACT 6VV NOWOS.ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) ©/r USE OF SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER y so as to become subject'to the Workers' Compensation Laws. OCCUPANCY GROUP =� � MAIL \ O ADDRESS I ,1 F-- Date Applicant ti w TEL. OCCUPANT LOAD n- NOTICE TO APPLICANT: If, after making this Certificate of clrY No. —� z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKINGSPACES READ PROVIDED License Number Lie. Class LIMITEDTIMEUSE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZEOF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date /V) HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING p I, as owner of the property, will do the work and the SPACES PROVIDED z 0:8 3,f�Q structure is not intended or offered for sale (Section 8 818 9 d trs'z 7044,Business and Professions Code). I Q, 5`'8$ CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency r 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 Jv ' I have r a this p kation and state that the i r tion is r ect.I gr c mply with all County ISSUANCE FEE d Sta s ela g to uilding construction,thor epre n tives o this County o enterTOTAL FEE @-ment- ned o erty for nspaction pu oses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat'- Il4p mi ee ate