Loading...
HomeMy Public PortalAbout9564 LAS TUNAS DR_Miscellaneous__ WORKERS,',C&MPENSATION DECLARATION CE876 (11-84) M.I SC E L LA N E O U S APPLICATION • �-' - CE 875 I hereby affirm that I have a certificate of consentto 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 �S(�t( FOR APPLICANT TO FILL IN BUILDING — ` ADDRESS V S 4J Certified copy is hereby furnished. . LOCALITY BUILDirIG AD '�_ ,� 1,566 ,� DRESS 5 Certified copy is filed with the county building inspection department. LOCALITY _ NEAREST y� C CROSS ST, U Date Applicant - ' NEAREST DIS ICT NO. G UP TYPE /// PROCESSED BY CROSS ST. U � CONST.' / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / V COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR +N- LOCAL NO. OF BLDGS. (This section need not be completed if the work 1nVOIVed TRACT NOW ON LOT � US ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) 1 SIZE OF LOT ` USE STONG BLDG. ./ - - - 7- 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 y so as to become subject to the.Workers' Co cation Laws. MAIL 2. CD r ^/ ,^^ 0 _ OCCUPANCY'GROUP'. �,, o ADDRESS 1 `v L I F__ Date lS� Applican W ' /nMp�' n TEL' OCCUPANT LOAD D_ NOTICE TO APPLICANT: If, after ma ' g this Ce ' icate of CITY' LC�'Ii1lJ�+L/�F No. 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 USEGEOLOGY INSPECTION ❑ deemed revoked.. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION occuawrvcY 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 nes§ and Professions Code, and my license is in full force and /�-� effect. • l.__ _CQPARKING REQ•D PROVIDED • SPACES License Number Lic. Class foL LIMITED TIME USE . Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTORS 2 acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. oo STORIES s NATURE iness and Professions Code). FINAL APPROVAL 107� PRESENT USE OF BUILDING - Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. F 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 I, as owner of thero ert SPACES PROVIDED p p y,.will do the work and the structure is not intended or offered.for sale (Section z 87 9.3 A 7044,Business and Professions Code). o.o,o's 88 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING p o, o o a,o o z I hereby affirm that there is a construction lending agency < — O 1.1 '5,`'8-8 for the. performance of the work for which this permit is. issued(See. 3097,Civ.C.).- Lender's .).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 ordinances and State laws relating to building construction, . and hereby authorize representatives of this County to enter TOTAL FEE upon the above-mentioned property for inspection purposes. �— SEE REVERSE FOR EXPLANATORY LANGUAGE. ature of mittee Date WORKERS'COMPENSATION DECLP RATION 76M444 ` A p�� CE 875 (2-80) ': MISCt-LL/`9.I,iE®US /°1�'f-' 1v/`1T.�;ON , L h reby.affirm that''I Ihave a certificate of:consent' to„self :- ' COUNTY OF:LOS;ANGELES'- ' BUILDING AND:SAFETY DIVISION anSUre•Or aCertlficate-Of Workers',Compensation Insurance or'.�' - - ..< _ _ - - a certified copy thereof(Sec'.3800,-Lab' C.) „i; - Policy No Company BUILDING / - .. ADDRESS ' ' FOR�APPLICANT TO FILL IN' +: U.ILDING •eCertified'"copyls hereby furnished : Loc ALITY DRE OCertified copy is;filed with the county building inspection'" Lodwl irv` NEAREST "d`epa`rtment.- CROSS.ST Ent .- _ ,, :.. - - _ �TY PE'l C, SED•-�6Y Date Applicant 2 IC 0 �. .. ,- NEAREST NO: GROUP C ROSS;ST. q CONS CERTIFICATE.&EXEMPTION FROM WORKERS : LEGA L. ,` J ! L_- , "DESCRIPTION LOT NO BLOCK 33 CL�fv COMPENSATION INSURANCE: M e. - RI�NwAv' .� .+ , (This section.need, not•be completed if'.the,work involved TRACT• NOW ON USE'ZONE' SPECIAL-CONDITIONS TA by,'the,-permit is,for one,hti.dred dollars ($100) or less:)" usE°OF, - EXISTING OV, „ - � .. � AL `certlf ' that in the erfOimanCe' SIZE OF:LOT EXISTING BLDG y3' �'• : . I„ y p of the•work for which this : 7, 0 ,•:,permit:is.issued ;I;Shall'nOt;em pl O•y any person in.any manner. WNE;R94' S.; O L/ - _ /7/T so as to become subject'to the Workers Compensation;Laws, OCCUP.ANCY GROUP ..•., t - MAIL ADDRESS-!,'��© S1: Dane AppLcant " :, .:. -; .. NOTICE TO APPLICANT: If, after,malung this Certificate of Iry ; .�}r_H, .a`�A -` No', .. OCCUPANT LOAD ^.z Exemption•,`,-you„shoul-d'beco me'-isubject to the. Workers'-, �.•,. Oompensation provisions of the` Labor Cod e;.you.iriust`forth' ' APPLICATION FOR EXIT HARDWARE With ,COmply Wlth. SUCK-.p rOVISlOrlS'IOr, th1S,permit Sh all•be. TRAILER U,SE e.G EO LO GY'INSP ECTION -t -`N deemed revoked xr ❑ ,� ' Spec OCCUPANCY+INSPECTIO o :Know Panic Devices LICENSEDCONTRAC TORS:.DECLARATION I;hereb 'affirm' that`I am licensed under 'r” p saFerY,iERn�rr (Llsr:ir,Eais'eEiow)• - y' p ovisious of Cha ter I--I . 9.(commencing with_Section'7000,).,of:Di`sion:3'of the Busi- L 1 Ex rrs 1 NO: OF ness and Professions'Code, and my, license is in full force.and .effect. ':. R.Eq D PROVID ED c ' PARKING License Number Lie.Ciass SPACES,, '� Contractor ,.. Date LIMITED " - `"T-IME .USE _-,. ... ._ - .. . �O ATE -. '- ATE - -' FROM': � TO 0.,. I am exempt from the,lic ensrng requirements as 'I am a t ' licensed architect, or>'a registered professional engineer,'-' SIZE OF" +'- .NO OF - ;EXIST,ING BLDG " ^.'' ;.r_ ' 'STORIES , acting:m my professional.capacity (Section,7051 Bus= ' INSP. - - .::. ,. '-•. :: - - "SIGN ;-.iness'and Professions Code - ) ' ••..., RESENT USE�'OF BUILDING ."".�. FINAL APPROV/A I�-.Y'..'. - E Lic.or Ree.No Date ` 140. 6F EXISTING B TILDINGS'' - HOME OWNER-BU ILDER•DECLARATION,., ...r ON,LOTAND`USE .. T I 'hereby•affirm`that I,am.exempt• from;;the Contractor's• r License Caw for;the ,following"reason (Section 7031.5, Busi- t z:LJ, .:nes"stand Professions'Code) No-FdIiFCING 5 d 3 A ,. '. SPACES,PRO,V ID ED7. ». .. i - 0 I as owner of the property', will do''the'work;and the, # o structure is- not intended for,sale (Section,'`' 7044;Business and Professions;Code) 2 S 0 - ROPOSED USE:OF BU,•ILDIN'G :.. .. - CONSTRUCTION<LENDING AGENCY O:O ,I -hereby,affirm 'that there :Is; a construction'lending agency; 'for,`the erformance'of.-th"e''work for wJiich th's p - -Permlt Is issued,(Sec. 3097,Civ.'C.).. TM» 032;6 81:M Lender's'Narne ;. PROPOSED MAX.OC C.-'- • Lenders Address ., PERM I_T.FEE'.. - I certify that,I_have read this application an( 'state that the ,* - f ISSUANCE FEE above information is;correct.:I;a ree to'comply all County g _ ordinances and State, laws'relating:to'"b'uildirig construction, s and-hereby=authorize representatives of this:County to enter:: ' TOT:wt Fee10-57 pon,the ab ve-mentioned.pr6perty'fo�_inspection•purposes: SEE-REVERSE F X ANATORY LANGUAGE y Signature Permittee Date 8' v. �:1 .. � "<. r 76M4_44:x.. :.._. - Ate+ - ,,,�WORKE�2S COMPENSATION DECLARATION', ., Iv,'ls� -LLf'�Il1E®LJ� APPLICATION' 20 0063DPW12/90 '( - - a. W _ ION. 1;:1 v,affiiin that i have.a certificate of.consent.to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIMS Insu f or a certificate of,Workers','Compensation Insurance, or a certified'copy thereof:(Sec.:3800;'Cab:' C:) Policy No. �sCompany i :;. >,. ,t FOR BUILDING ADDRESS - ' DRESS •u t APPLICANT TO FILL IN Bu a+ AD Certified copy is''-heieby,`'furnished r :,,. _ =t;=r>y. : r. '-LOCALITY : ❑ -Ceriified;go"py is filed`wtth the county•bwldmg,tnspectio.n CITY zip'. . NEAREST "departmept;,.. ';,r a t ,.N , , ,a.., T21?1° 1 . G..t 917�.� 4. t ,.. Date` 1 aAppI a SIZ OF LOT NO.OF BLDGS.NOW ON LOT DISTRICT NO., ' GR UP; TYPE ESSED BY' 549 ' 2 CERTIFIGAT—If OF;EXEMPTION;,FROM WORKERS r �o .. TRACT - BLOCK. LOT'NO: •�Y '�'"' t ,CCOMPENSATION INSURANCE MAP .• Hi�NwnY _ 1. .., CO : } NO. .^.i WOR'KERS COMPENSATION DECLARATION 76M444 - APP L'LC/�T:I®.fV CE 875(280)-. MISCELLANEOUS,, hereby 'affirm that I have-a certificate of consgnt to self- 'I COUNTY'OF LOS ANGELES BUILDING AND,SAFETY.DIVISION insure or a c�rt&tate of Workers p Com ensatio,n Insura nce or certlfted coj thereof(Sec•3800 I ab C) Policy No s 'Company FOR APPLICANT TO FILL IN ,= wooeEss ❑ Certified+co is'hereby furnisfied,' y uILPING, Loc•Ai ry pY - ,, ADDRESS 1: ❑ Certified copy js',filed.with the'counfy building`inspection; _ WARE sT ' LOCALITY - ,department CROSS ST Date' Applicant EAREST TYPE q DISTRICT NO G OUP PRO SSED-'BY C, , CROSS:ST. •_� CONST r' CERTIFICATE OF EXEMPTION"FROM'WORKERS pEscRlPnoN roT'NO. BLO .'LEGAL , •.:..n , "- MAP .. HIGHtWAY' COMPENSATION'INSURANCE ,: .-.: r• - .., . t - CK NO. (i__IRC LE) a .,. - .. ..t... ,r... .. .. r NO�.OF BLDGS Y n'. (This';section need not.be'-.completed if the;work involved TRAcT NOW.ON'LOT USE ZONE •SPECIAL'CONDITIONS TA MAJO by,jhe�permit;is foi:'one hundred:dollars '($100) or less.) use OF TE R SECOND LOCAL •_, I SIZE OF LOT - _ EXISTING BLD G _ �. I"certify fhat in the;perform'ance'tof'the work for which this ." _ O permit Is Issued,.I shall not'employ any person'in any manner _WNR H so,;as to become:'subject'toalie Workers;Compensation Laws. ��, OCCUPANCY GROUP W- ;. ..... ... - ADDRESS - ..'- Date A'p'plicant: NOTICE-TO APPLICANT: If;,'after' making this Certificate of Iry G rvo.' G OCCUPANT LOAD Z Ezemptiori, you, ,`become.subject�to 'the,.Workers'.' . :.' APPLICATION FOR EXIT HARDWARE Compensation provisions of,the Labor Code^you must-forth-:: _. _ uch`• provisions' o"r .this .permit shall be TR AILER.'USE GEO LOGY INSPECTION deemed revoked illi`s` comp y. ❑' No Spec.'Know)' ❑ El LICENSED CONTRACTORS DECLARATION ON ❑ ' V OCCUPANCY'INSPECTI :.is •. '. ,. _. 'Panic De :ices I hereby'affirm'that I am licensed under provisions of Chapter §AFEry PERMIT ❑ (LIST ITEMS Below) -• - - .r NO. OF EXITS 9.(commencing•-with,Section 700o)'of.Division 3 of the Busi ` " . ness-and Professions Code and my license Is In full force and 'wRKiNG effect1. REQ D PROVIDEDU"z ' _ SP'ACES' ' License Number Licr Class \ (C i IMITED.TIME° USE - - Contractor Date. OATE" DATE, ' - .. .. F R O M T O: x ,.. I am,exempt from,the licensing requirements-as'I am a 'j licensed,architect or'a:"registered' professional"engineer'-; !SIZE OF` NO. OF' ISIGNATURE i NSPECT S acting`in my:professlonal^capacity, (Section'7051; Bus- ?' EzisTlrvG BLDG­ sroRlEs mess and Professions-Code) „° RESENT us eulLDirvG FINAL APPROVAL Lic.or Reg.No. 1 Date 0 O_ HOME OWNER BUILDER DECLARATION, _ o f~r" O. OF EXISTING _ UILDINGS N LOT AND USE - I hereby •affirm.that I":am'exempt, from -the Contractor's . "aS E License Law-for thetfollowng reason_(Section 703`f.5, Busi - .. NO PARKING" ness`and Professions Code) SPACES PRovioED, ' tIt I as owner* of-the,property, will do the,;work'and the - ; structure is `not"1 intended'oi offered-•for_.'sale (Section:,; ' 7044•'.$usiness'and Professions Code). - - -; PROPOSED USE BUILDING ._t OF i CONS TRUCTION LENDING AGENCY I hereby.affirm that, there iS=a construction lending agency for-Abe.performance::of the`work for which• this permit is {issued (Sec..'3097 Clv'.C). "" `` Lender's Name :_ . %' PROPOSED-MAX. OCC: Lenders tL,d4ress PERMIT FEE' I ter t at ve a hi pplication and state that the abo e.'n r ati cor ct. e to comply with all County IssuwNCE FEE ordi ce a d' t IA r'e i to building construction;E TOTAL FEE . and e by a ho ' repr ent i of this County,ao:enter- upon h;, a v 'me e o r 'for inspection pAposes. SEE,REVERSE'FOR EXPLANATORY LANGUAGE- / o e ttee D t - ;, Y