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Home My Public Portal About9559 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 r -: CE - M I:SC E L LA N EO U S .APPLICATION 875 11-84) I hereby affirm that•I have a certificate of,consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, c:certificate of Workers'Compensation Insurance,or I 1 p 'fl a certified copy thereof(See. 3800,Lab.Q. Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS ✓ `.J � �,� Certified copy is hereby furnished. ADUILDINGDRESS /C S f7111E LOCALITY Certified copy is filed with the county building inspection ocALITY —�` NEAREST department. (ej►Z I� /�t ceoss s AREST y.. �•� DISTRICT NO. UP TYPE ROC SED BY Date Applicant CROSS ST. -re('l1 `Q„ 6 /1 At4. I�evC !amu Z coNs T ` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L/ COMPENSATION INSURANCE DESCRIPTION IL N BLOCK MAP Hl "WAY NO/ �� (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work mVolved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (8100) or less.) uSE'.OF SIZE OF LOT EXISTING BLDG. I.certify that in the performance of the work for which this emu � _ . o permit is issued;I shall not employ any person in any manner OWNER v � e. ( _ ANN C�H1LI so as to become subject to the Workers' Compensation Laws. AIS OCCUPANCY GROUP / o !✓ Date Applicant A RESS s \� a TE L.Q(� a� p OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY � No. U Exemption, you should become subject to the Workers' APPLIC4TION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code,you must forth- with comply with. such provisions or this permit shall be TRAILER USEY GEOLOGINSPECTION El deemed ❑ [E] ..No 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 PAR effect. SPKING ACES . REq'D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ 1 am exempt from the licensing irequirements 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). RESENT USE OF BUILDING �AME� �T�KE — FINALAPPROVAL ' Lic.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 6 ❑ 1, as owner of the property, will do the work and the svnces PROVIDED ! r 960 i�4 A structure is not intended or offeredrfor sale (Section V 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY OPOSED USE OF BUILDING CORN EN f, o D o e o a o z I hereby affirm that there is a construction lending agency L 62170 CQ L hfrE for the performance of the work for which this permit is _ ( 202-6- 8 6 issued(Sec. 3097,Civ.Q. OTHe& C N /C-9 — ( op Lender's Name S'H�LI/�S 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 ordinances and State laws relating to building construction, j and hereby authorize representatives of this County to enter TOTAL FEE uppn the above-mentioned property for inspec ion purpos s. �� l•/ � (I L SEE REVERSE FOR EXPLANATORY LANGUAGE ,� Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76M444. CE 876 (2-80) MIS.CEL;LA.NEOU'S APPLICATION I hereby affiiin that I,,have a certificate of consent to self }' insure, or a certificate of Workers'.Compensation Insurance,-or COUNTY OF LOS ANGELES BUILDING AND SAFETY,DIVISION. a certified copy thereof(Sec. 3800; Lab C) . Policy No: ,Company FOR APPLICANT TO FILL''N* BUILDING .' 'ADDRESS Certified copy is hereby furnished. ` BUILDING' �. ',LOCALITY 0 ,Certified copy-is filed with the county building inspection A REss NEAREST D department. L ALISY — ,� CROss ST 't Date' A IlCant EAREST_ DISTRICT GROU TYPE PROCE SED`'BY PP - '..' r. ROSS ST. _ .CONST. - C /4' CERTIFICATE OF EXEMPTION FROM.WORKERS LEGAL �' COMPENSATION INSURANCE oEsc RlPnoN . LOT NO. BLOCK IMAp HIGHWAY • '. - •" 'ry O. " (CIRCLE) STATE MAJOR SECOND LOCAL Q, NO. OF BLDGS _ (Tills section need:not.be completed lf-the WOrIC InVO1Ved' TRACT NOW aON'LOT USE ZONE SPEC IAL"'CONDITIONS' O by the',permit-is for..one hundred ,dollars ($100) or less.)'_; U USE OF - ' SIZE OF LOT ' EXISTING'BLDG - I certify.that in the performance'gf the work for which this permit is issued, I'shall not"employ,any person many manner WrVER ` - �! "1- so as'to become subject to the Workers' Com_pensation Laws. OCCUPANCY GROUP W MAIL' ' .. ADDRESS . Date .:Applicant l ' TS TT' U) � , NOTICE TO APP'ICANT:`If, after making this Certificate of cliv No� ''y 7/77t OCCUPANT.LOAD z . Exemption,. you .should become 'subject to the Workers' APPLICATION FOR 1 EXIT HARDWARE: Compensation provisions.of the Labor.Code,you must forth- With comply .with such provisioris' or this �permlt.•shall be, TRAILER USE GEOLOGY INSPECTION - deemed revoked. - ❑ ❑ y I No Spec. KnoWl..❑ LICENSED CONTRACTORS DECLARATION, occuPAlvcY INSPECTION i� Panic Devices Q I hereby affirm that.' am licensed under-provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) ry0. OF EXITS 9;(ccimmencing with Section 7000)'of Division 3s the Busi- neas and Professions Code, and my license is in full force and ; effect. REQ D PROVIDED PARKING . . , -; SPACES Lieense Number Lie.Class LIMITED TIME USE ' Contractor Date' DATE - DATE I. -0 I am ex'empt from the lic.ensing.requirements.as I am a' '' licensed-archite Ct'or' a.registered 'professional'engineer, SIZE OF' NO. OF INSP.E CTO R's acting In my professional. capacity (Section:7051,,Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL 1 _ ESE NT USE OF BUILDING" Jq Lic,or Reg.No. Date � V HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _,23 " X23$, 1''N .- � ".i ON LOT AND USE - _ •- I hereby affirm that,I am exempt from the .Contractor's # o.o o o 88 ' License Law for the following reason (Section 7031.5, Busi- NO. PARKING _ /`, - nessand Professions Code):' SPACES PROVIDED _ ID.e lO,O O'O,O 1,` as' owner. of the property, will,do the.work and the, Q (�`2 9x 84! structure is not-Intended or offered for sale-(Section 7044;Business and Professions Code). .. OPOSED'USE OF BUILDING 'L 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 t 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 (C� / :and hereby authorize,representatives of this'Co my t0 enter TOTAL FEE upo =the above-mentioned.property for inspe on purposes. , SEE REVERSE FOR EXPLANATORY fLANGUAGE L . Signat a of PermitteeDaate 61 1 W6kKERS COMPENSATION DECLARATION_ SCE Ml cc //�� NEO (� /� p T w 76875(28012. .7�E�L/"1IV,GO�S•I /"iPPLIC/' TON I.hei�eby;affirm' that.-I.have �a`.certificate" of consent to.self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,or a'certificate,8i'Workers'Compensation Insurance,'or a.certified copy thereof(Sec;.3800,Lab O':) Policy No:' Company FOR APP LICANTTO FILL IN'' wooRess.r K 0' Certified copy is hereby furnished: VIS LocwLiT'v (LOIN Certified copy-'is''filed with the county,building inspection NEAREST a department : 1 L ' ''C ROss'ST * - �. NEAREST '"' `. ,,a- STRICT NO.'` GRO P TYPE' PROC SSE y.BY Date Applicant Te CROSS ST I:rr:iJhl� :,..�'�' �` CONST I CERTIFICATE.OF-EXEM'PTION`EROM;W,ORKE'RS 4E�wL '. D I - w DESC R IPTION LOT3'NO y. 11 L BLOCK /� '.i S -MAP HWA COMPENSATION INSURANCE - ,.._ � MAJOR SEGONDALOCAL _:Y+ NO':'OF BLDGS ��' s (This section`,neednot_be "complefed If..the two;k InVO1Ved, '- TRACT: : NOW ON LOT' USE;,ZONE .S P,ECIA L;.CONDITIONS TAO" by'.the permit Is'for one hundred dollars`($100) or less. " Y. USE OF' L� '..:' performance, ftlle^ E OF LOT't_.• " EXISTING BLDG.. - L:certify:that:In the o work for which this ' O4YNE.R .. aF`b�`t►d i n 'pertnib.is issued I shall no`t ernploy any person In any manner- .Ll a s' Compensafion'Law'.. wiu'_ so as to become subject to- Worker. OCCUPANCY GROUP Z' Date` Applicant. Z. NOTIGE`,TO APP.I ICP NT If,' after mat mg this.Certificate.of'_ Tv NOL "OCCUPANTICAD z; le �� .6 Exemption;, Exemption;, you=should, become subject'•to -the Workers'e 'APPLICATION Compensation provisions-'of the Labor Code, you-must forth FOR EXIT HARDWARE with comply Wlth .SUCh'.'prOVlSlOr15, or this,:permit, Shall, be 'f -TRAILER USE, •'' GEOLOGY INSPECTION' N •.Kn �/� deemed revoked ❑ O SpeC., o ❑ OCCUPANCY.INSPECTION Panic Devices "•❑ . LICENSEDCONTRACTORS DECLARATION Lhereb'`affirm that.I,am,liyepsed under rovisions of Chapter' swFeTv,PERrvSIT' (Liss ITEMS 13ELowl, :: O.�OF EXITS' :9 (commencing Witfi,�Section 7000),'of Division 3 of.the Busi' N ness and Professions Code,and my license-is'in full force and' effect.. `-', PARKIN!G ,:REQ D '� PROVIDED SPACES=�' License Number Lic.Class ' LIMITED TIME-"USE _(.'OntiaCtOr_:`. . . <: Date '. - 1. < .DATE FROM•.:'.- n TO , a, I am,exempt•.from ah:e licensing requirements as I am a' licensed•'mpt,,eCt Or;'a regisfered piofesslo`naL;engmeer- SIZE OF :', k, IN'O OF ' acting it ,my._professional capacity(Section 70'S,t'•.Bus-. EXISTING BLDG. „. ' ��r STORIES _ g iness;and;Professions;Code) ;° R s rvT usE of eu1LDING FINAL;APPROVAL _ INSPECTOR S a.£. - :. . r SIGN 'Ic:or:Reg..No: , Dat ' - '" '`<' 'N O,'OF EXISTING BUILDINGS - - -, HOME OWNER-BUILDER DECLARATION oN:'LOT ANo,US �rar_ �. y form that I am.exem t from the ' I: -ere a �' Contractors °,• ;;a- License Law,:for the`following reason (Section 7031..5, Busl- = . nesSan d Professions-Code)" ° ' No.ewRKRO I -' ��';� "�-" sP'ACES'PROV-IDED ' 3S7A :I, as owner of,.the.property"will do'the,work and the'° o # o oc a 4_,� t: .. •structure Is:nof_intended oroffered-:for-sale,.(Secrion.` -7044, Business`and>Professlons Code) a o e ,v o a o{ OPOSED USE OF BUILDING 'I' _ UCTION,.LENDING AGENCY - I heieby,'affirm' that.there:ls' a;constluction4' Ing agency �t� CONSTRUCTION for` the, performance of"the work'for which ,this'permit;is ' issued,(Sec. 309.7„Civ.C). L-ender's Name,' ;•k, PROPOSED,'MAX 'OCC Lenders Address - PERMIT FEE' , , r' I certify,.that I have•read*this application and State that the above,information is.correct. I agree;to comply withr all County,'.:, yISsU drvice FEE ., .. g. g ordinanclaws es:and State .gelatin td btiil'din construction, •r H and`hereby``authonze:,representatives.of this County toenfer TOTAL FEE. pon th toned property for ui�pectlon purposes.' SEE REVERSE FOR EXPLANF.TORY,LANGUAGE Signature of Permittee Date , WOR'KE,RS'COMPENSATIONDECLARATION' 76 CE 875.(2 80). "' MISCELLANEOUS A r p-,. - '/`1T IO V I:hereby^affirm`that`I, have: a certificate of:consent,to' self CaUNTY:OF.LOS ANGELES BUILDINGAND SAFETY DIVISION insure or,a„certificate of'Workers Compensation Idsurance;or a�_'rtified copy thereof(Sec 3800' 7. P• Policy No. Company r $ _BUILDING FOR''APPLI'CANTTO FILL IN:-- ss, J' ❑' Certified copy Is',hereby.'flirmshed;` '- 'r • --' U I I:D I N G' - - „ ., � ��` - LOCALITY .: - ;ADDRESS "� , s tz. r Certified copy ls'filed with the county building mspectloNEARES - department Gf.j Ross sT OCAi:ITY •� v., ,� '{•Date ;Apphcant AeEST _ TYPE . •, +`, '•, a CROSS ST ,'~ R - CONST .. , ;P - .LEGAL - �I•� �U� B1Y f . GR PRO E ED c ” Z I!D IVIJI -CERTIFICATE•OE EXEMPTION FROM WORKERS ,, ;. DESCRIPTION LOT"NO - BLOCK COMPENSATION INSURANCE, ?. oF'BLOGs NO (cIR LEI STATE MAJOR SE ND LOCAL a (This $eetlonheed,Clot be,&6nipleted_If•,ihe work-,- VO1Ved` TRACT NOW ON:LOT USE ZONE[�sf.ECIAL'CONDITIONS by_the'permtt ls-,for one hu"ndred dollars.($100) or, less.) use°oF SIZEIOF L'OT'., EXISTING-BLDG V cy . I certify that in.the.'performance'of the.work.for which.this r " �.r. ermrt is'issued, I shall not km to 'ari owNER 1' l t- P P Y Y Person m any.mannec` : �J, "'x�$L7i �� ' cC l 9 f U,;• so as subject to,the Workers' Cornpensation Laws. OCCUPANCY GROUP W_ .. MAIL... - .. ADDRESS.{. - r "A licant` ' CtN � ,cn DatePp TEL. � :,z-'.;;. NOTICE TO-APPLICANT: If after-making this Certificate.of'., ciry �'' .NO. OGCUPANT'LOAD Exemption,,you, should.,become sublect''to the, Workers'. ' APPLICATION FOREXIT HARDWARE: Compensation'provisions'of.the Labor Code,.you*must forth With comply with such.,provisions or this. permit Shall.be.., TR AILSR,U.SE "" -,GEOLOGY INSP•E CT10N C deemed revoked pe . K ❑ ❑ No�S nowt: ❑ LICENSED CONTRACTORS'DECLARP TION' ,OCCUPANcY'iNsPEc ION Panic,Devices I hereby affirm that C'am'licet sea under proyisions.of Chapter:. a 'SAFETY PEiir�IT (LisT ITEMS BEcow) .,v - ., -:.❑ NO..OF•EXITS' 9 (commencing with_Section 7000):of Division 3 of the Busi nes and Professions Code,':and my license Is to full foice and v effect SPAC ESP.ARKING REq D PROVIDED License-Number Lic Class LIMITED TIME USE Contractor "'Date :, o nTe :DATE FROM: �`. + TO ,:. ❑ :I am exempt from the•,licensmg•requirements asA am a' ' licensed'.'aiCh It ect 'Or. a'-,rl'gl Stered pro fe5sional .engineer..,, SIZE o,F '-. ' - . YVO. OF ' - acting in-my professional cap acity '(Section'.7051, Bu's ExisTiNG"Btiliy. STORIES mess°'and ProfessionsCode) FIN ALAPPROVAL INSPECTOR S st ATURE Lic.or Reg:No ' Date SENT USE OF BUILDING 1:� i A+t a� NO. OFq EXISTING-BUILDINGS HOME OWNER,BUIL DER DECLARATION .,,,.. ... ,.. . ON LOT AND USE _•_, :. , I•,hereby affirm that I am,exempt.from-11 e 'Coptractor,'s `,License.Law,*for tlie;following reason-(Sectioii7031.5, Busl ness,and-.Professions.Code) , S ACEs.Ptiov DED= ❑' I as owner of the property,'will dorthe work-and the y ;- structure is noYintended or;offered 'for sale (Sectign ? 7j;]Q 2 A 4. 7044, Business and;Professlons Code) ,ti, - ' : - OPOSED USE OF"BUILDING" •.� # . . . . g A,_ CONSTRUCTION LENDING AGENCY p 1 I hereby affirm that'there,'is a constructloir:'+lendirig,agency.4- e'p fl - r7/�A t �,o A o o e',o o a o.z for the' performance of the•work`'for Which this,permit is issued(Sec.r300;Civ.C.). K Lender shame PROPOSED MAX OCC Lender's Address PERM iT FEE'i- _ I certify that I have-read ,this'applicatlon'and'state that the.' ., ;> . above information is•correct,-I agree to coriiply.with all County,, IssuA-NCE FEE ,ordinances and State'laws relating to.building'constiuction, TOTAL FEE'- and hereby,authorize representatives of.this County to enter' up' he;above- entioned-,pr perty for.inspection-piirposes SEE'REVERSE'F„OR EXPL'ANATORY`LA'NGUAGE Signature'of Permittee -' Date