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Home My Public Portal About9566 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 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. CompanyFOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. tA DING 'LOCALITY RISSWIR.0the ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP T E IPR SACD BY 'CROSS ST.. ONS'r CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - DESCRIPTION DESCRIPTION LOT NO. - BLOCK mAF I-IIGt•Iw Av COMPENSATION INSURANCE srwiE MAJOR SECOND LOCAL This section need not be completed if the work involved NO. of LOT USE ZONE SPECIAL CONDITIONS 0 ( p TRACT NOW ON LOT p Q by the permit is for one hundred' dollars ($100) or less.) USE OF U SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mannertD Raft 0 r. so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP U ESS U.J.Date Applicant NTEL• OCCUPANT LOADNOTICE TO APPLICANT: If; after making this Certificate of No. Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with .such provisions or this permit shall be TRAILER USE a GEOLOGY INSPECTION No Spec. Knowl. ❑ ' deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am liceNo. OF EX 'ITS under provisions of Chapter _ SAFETY PERMIT [� (LIST ITEMS BELOW) ITS ❑ 9 (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 REQ'D PROVIDED LicVnse Number Lie.Class LIMITED TIME .USE Contractor Date DATE DATE % - FROM: TO: �ia {-i am exempt from the licensing requirements as I am licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR`S acting in my professional capacity (Section 7051, Bus- IS TING BLDG. STORIES SIGNATURE iness and Professions Code). F BUILDING FINAL APPROVAL ESENT USE O Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I , I hereby .affirm that, I amexempt. from the Contractor's z O b� A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING #llo,o:o'o,,�8 SPACES PROVIDED ❑ I, as owner of the property, will do the work and,the to..o'o'o'o'o o z structure is not intended or offered for sale (Section' I� 3' •61_S J. - 7044, Business and Professions Code). OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY ��O 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 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, a d hereby authorize representatives of this County to enter TOTAL FEE pon a above-mentioned pr erty,for inspection purposes. SEE REVERSE FOR EXPLANATORY_ LANGUAGE Signature of Permittee Date WORKERS' CUMYhNJAl 1V LV LJCI LHKHI IV lV 20-0063DPW!2/90 �dl-1_✓t-+r.L L f-11�i G V U.7 E-1 r r L t`a B .a va i I hereby.affirm that I have.a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING>AND SAFETY DIVISION P ;insureor a certificateof,Wgrkers' Compensation Insurance, or a certified copy thereof (Sec.3800, Lab.C.) Policy'No. Company FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS ADDRESS j ❑ Certified copy,is hereby;furnished g ' Y , LOCALITY , ❑ Certified copy is filed with the county building inspection cillf IP department. CIn_1 NEAREST. 0 1" -CROSS ST. Date )' Applicant SIZE OF L T NO.OF BGDGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY coNST. CERTIFICATE OF EXEMPTION FROM WORKERS' O TRACT BLOCK LOTNO. V COMPENSATION INSURANCE NOP CRCLE)Y STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL tY by the permit is for one hundred dollars ($.I00) or less.) USE ZONE SPECIAL CONDITIONS O �y er TEL No. L I.certify that in the performance.of the work for which this �- f LU permit is issued;I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. AD REQS// Y OCCUPANCY GROUP Z b Date Applicant CITY ZIP NOTICE TO APPLICANT: If'. after making this Certificate OCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE: comply with such provisions or this permit shall be deemed- TRAILER USE❑ GEOLOGY INSPECTION❑ revoked. No Spec.Knowl. ❑ r� LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 58 Panic Devices ❑ I hereby affirm that I am.licensed under provisions of Chapter_ SAFETY PERMIT❑ (LIST ITEMS BELOW) a 9(commencing with Section 7000)of Division 3 of the BusinessNO.OF EXITS and Professions Code,and my license is in.full force and effect. .. are O uslness PARKING• REQ'D �J PROVIDED License Number Lic Class All I-A 61 SPACES I Contractor Date LIMITED TIME USE I ❑ I amexempt L from the licensing requirements as I am a DATE DATE licensed.architect or a registered professional engineer FROM: To: acting in my professional capacity (Section 7051,Business SIZE OF NO.OF INSPECTOR'S and PIOfeSS10RS Code). EXISTING BLDG. STORIES .SIGNATURE, Lic. or Reg. No. - Date PRESENT USE OF BUILDING FINAL APPROVAL 15,__Z-03 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS I ON LOT AND USE _ I hereby affirm that I am-exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): NO.PARKING G( �0-f b' SPACES PROVIDED. PA-n ❑ I, as owner. of the property, will do the work and the structure is not intended or offered for sale(Section 7044,X PROPOSED USE OF BUILDING Business and Professions Code). I � - 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.).. PROPOSED MAX.OCG Lender's Name A I �/Q `I�� J�� {„J �'( APPLICANT(MNT) TEL NO. Lender's AddressS_�_C� it - A`i`r-I tbluy_1 � .ADDRESS .. I certify that I have read this 'appl)cat n a�qdl t that th above informationis correct. I agree to comply With all County PERMIT FEE . ordinances and State laws relating to building construction,and hereby authorize representatives.of.this County to enter upon ISSUANCE FEE the above- entionedproperty for inspection purposes. TQTAL FEE L” 1 - 30-0 > SEE REVERS£.FOR EXPLANATORY LANGUAGE Signature of Permittee Date