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Home My Public Portal About9560 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DrCLARAf1oN CE 875 (11-84) M ISCELLANEOUS APPLICATION CE 875 I hereby affirm that i have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or , I�1r ,I a certified copy thereof(Sec. 3800,Lab.C.). ®� Policy No. Company FOR APPLICANT TO FILL IN ADNG DR SS AD DRESS Certified'Copy is herebv furnished. pp BUILDING U ` 45 ' 1 � � _ A ADDRESS -•r� 'LOCALITY O i Certified copy.is filed with the county building inspection g LOCALITY NEAREST KJ department. ` ( ,-{f%Ir 1 CROSS ST.. Date .applicant NEAREST +rye - DISTRICT NO. � GROUP TYPE ED BY CROSS ST. Cf7 _ �! O G �{ CONST// _ ! CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL // '••J! // (_O.MPENSATION INSURANCE DESCRIPTION LOT.NO. I.L.C. MAP HIGHWAY _ NO. (CIRCLE) STATE MAJOR SECOND LOCAL ' NO, OF SLOGS. (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 (SIOO) or less.) OF SIZE OF LOT I certify that in the performance of the work for which this — permit is issued. I shall not employ any person m any manner X OWNER 5` i - 09 v so as to become subject to the Workers' Compensation Laws. g OCCUPANCY GROUP MA - ADDILRESS Date applicant -7 NOTICE TO APPLICANT: If, after making this Certificate of g CITY jl_� NO. 2-�3'Z2J-(, l OCCUPANT LOAD Exemption, you should become subject to the Workers' AppLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code. you-must forth 1 with comply with such -provisions oI this per-mit shall be TRAILER USE I 1 GEOLOGY INSPE'CTION -7 No Spec. Knowl. E deemed revoked. LICENSED CONTRACTORS DECLARATION OCCJPANCY INSPECTION FX 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 REO'D PROVIDED - SPACES _ License Number Lie. Class LIMITED TIME USE n Contractor Date DATE DATE ' N P 40 M: TO: I am exempt from the licensing -euuirements as.I am a z licensed architect or a re^_istered professional ermneer SIZE OF NO. OF INSPECTO s ? acting m my oroteisional canaClt`: (Section i0;!1. Bus- EXIS7:NG 3LDG. - �STORIES SIGNAT E iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING v Lie.or Reg. No. Date ! q HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS 0 it y ON LOT AND USE tat I hereby affirm that i am exempt from the Contractor's I License Law for the Following reason (Se(:tion 70.11.5. Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED a 1, as owner of.-lie property, will do the .vork and -lie structure is not intended or offered for -,ale (Section 1044.Business and Professions Code). v A PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I herebv affirm that there is a construction lending ;ieehcv l for the' performance of the,work for which this periiit is I i issued(Sec. 3097,Civ.C.). I E6j Lender's Name CC I=. PROPOSED MxK. OCC Lender's Address 25.00 L:I I certify that I have read this application and state that the PERMIT FEE r� rs fj� above information is correct. [,agree to comply%cith,ail C: unty ISSUANCE FEE 0I9, ordinances and State laws relating to building construction, rind lierebv author"„e representatives of this Countv to enter TOTAL FEE 25.00 !-• ! upon liabove-men 'o e'ity for inspection purposes: % � 1-14 P1 /� SEE REVERSE FOR EXPLANATORY LAM,4GE SI?natUr_ ��1.p'. Date WORK ERS'{(. MPENSAfIUN DL-.('LARAII(JIN IYIl5l.1tLL:.HN"ViGlJ1J.:." HI "r'L�et..Hl-:rvl� I hereby afilml that I hnvN ! a celtllltiile of con,,n)l I,) ,ell COUN'I-1' OF 1_OS ANGta f:S BU'II-DING ,AND SAFETY DIVISION ins;ire,or a certlllrtte of Workers' Compensation 111NIITalicc. o tt certified copy thereol' (Sec. 3800. Lah. C.) Ih. J Policy. No. 'Y'omPaily F -• FOR APPLICANI TO FILL IN - Bu1LDING ADDRESS I Bl11LDING ADDRESS _ •:" - — _ '❑ (.cite(led U)P) I, he•Ith),.flll111SllCll: /?G;60 I /.1 Ti��c Or, LOCALITY ' . ❑ Certll led copv Is Illed wide the Counl) .budding in,I,cctllm ciTYl ZIP -- - - _ p NEAREST department. a ( O o cross sT:., Date Applicant SIZE OF LO, NO:•OF BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY '-• CONST. _ 1- CERTII I(AI'I OF EXLMPTION FROM WOR KI.RS ( = I - CNI:OLNSAl1ON INSUR-.ANIIc rnacr [BLOCK , Lor No. M-1P HIGHWAY .� • ICIRCLEI STATE MAJOR SECOND.LOCAL (This seclion need-liol he compllled_,il' the "mk ill\Ulr'ed ASSESSOR.MAP BOOK' PAGEPARCEL USEZONESPECIAL CONDITIONS - r. j by the permit is fur one hundred dollars (5100)-or less.! - - OWNER TELNO._ . I certil'y that In,the.performance of I11C%cork for Mlich Ill' b.ls permit is ISSUcd• I Shall not eniPIO} In) person Ill any maunu ;— - -- _ - sa as-to become subject ter, the.We)Iken' ComPensaliun I atvs ADDRESS j - OCCUPANCY GROUP 1 . Date Appllca lit'. CITY ZIP NOTICE TO APPLICANT: If. aIII:I nwking this (:erjil icate. OCCUPANT LOAD Of- Ezempti6n. \1611 shoUld become SUbjert to the Workers' ';I APPLICATION FOR — Coripensation prudisions ol'the Labor Code,you must 1lrtha'itll �dI EXIT HARDWARE: '- COn1pI)' Wlih SnC'h provisions or Ih IN Pli'llllt Nhall be ll t'inlld .')17"R AII_ER LISE❑ � GEOLOGY INSPECT"IiJN I_j I No Spec.Knowl. ❑ revoked. I— --, OCCUPANCY INSPECTIONK _ Panic Devices ❑ - LICENSED CONTRACTORS DEC AR AI'ION hereby affirm that I am licensed Under provisions-.61'( haPlel SAFETY PERMIT❑ LIST ITEMS BELOW I " - NO.OF EXITS^' - 9(commencing with Secfiun 70001 )f Di inion 3 of ilio BusuleSs y �l ❑ 3 and Professions Code,and m) license Is in full force old effect. r ,., � r' - I_ - _-- ---- - -----_.- - — _ .PARKING .• REQ D PROVIDED License NLII11beI' Llc. Class SPACES C - , - t ( C6ntnlctur llate I LIMITED TIME USE DATE DATE ❑ I aln exempt front the licensing re Ul LIIIelllCntN as 1 alll a -. FROM: TO: - z licensed architect or it registered prulessional engine cr 7 - acting Ill I lly'p.lolcssioll ll capacit1 (Section DCode).' 701 1 Bllsillcss 7SIZE OF _ - - - NO.OF INSPECTOR'S NS E SIGNATURE G . 1 I EX15ftNBLDGSTORIE S,and.Professions.Code). �/t-- LIC. Or Reg. NO.-- PRESENT USE OF BUILDING •v/ap q � / /� �/ "•PPt ,(A FINAL APPROVAL ` ` t a I 1IOME.OWNER-BUILDER DI:('1.ARALION Nu.oF LXISIINGBUILDINGs -- — 'ON LOT-AND USE I - hereby affirm thm,l am r:tempt Irunrilie Contractor', 1_1kCIINe -- _ -- - --- i Law for the following reason (Section /0315. Busine,s and --- Professions'Code): v NO.PARKING SPACES PRJV,IDED ❑;`l. as owner of :the Propene. )1111 LII- Ilse )folk --- StrLlCtnle 1N 1101 intended UI' olll'led IIII tale• (Scololl ilia I XPROPOSED USE OF BUILDING - • _rs j BIISIIICNS and P101eSSiunS ('Ode) C0*eku- CONSI RL(-I-ION I ENDING r\1(il N( l' l ll 1 hereby alfinn that there is a consliuction lending wcllc) fol the performance of the \,,mk• for Milch this permit is iNSULd — -- --- (SCC. 3097 CIVtC.). PROPOSED MAX.OCC.: - - �"�I Lenders Name _ - .-... _. - APPLICANT iPHIdTI TE NO: - - X' nik Q t 0 4� _qb Leader's Address ADDREs h i -'.`I certify that I liave read this application-anLod st rte ilim the 1,, five X00 above information is correct I agree to comply with U11 C ollnl) PERMIT MIFEE j ordinances and State laws relating to building conslfuclion_;old , ' herebyauthorize representatives of this CI)unt ter,cntt:r a)on P ) I ISSUANCE FEE the above-mentioned'property for inspection PLirpo,es. J - . , TOTAL FEE -� _• ' ,0- v SEF REVERSE FOR EXPLANATORY LANGUAGE_ °i Signature f Permittee-- Date