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Home My Public Portal About9579 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION msGre, 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 QADDRESS -- Certified copy is hereby furnished. UILDING �+ A RESS 6 U LOCALITY ❑ I 7 Certified copy Is filed with the county building inspection NEAREST � ,Q/J, department LOCALITY �� L ' �� cRoss Sr z/ Date Applicant NEAREST DISTRICT NO GRO P TYPE IPROCVSSED BY CROSS ST �` O O� r CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J a COMPENSATION INSURANCE DESCRIPTION LOT NO 3 BLOCK MAP 11��8� / HIGHWAY } ND QC (CIRCLE) STATE MAJOR SECOND LOCAL d (This section need not be completed if the work involved /- NO. OF BLDGS P TRACT t/ NOW ON LOT USE ZONE SPECIAL CONDITIONS Q by the permit is for one hundred dollars ($100) or less.) USE of ClSIZE OF LOT EXISTING BLDG r (r I certify that in the performance of the work for which this V 0 permit is Issued, I shall not employ any person In any manner INNER 6by( l — E —� L L£ so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUPAILW DDRESS a Date Applicant N NOTICE TO APPLICANT If, after making this Certificate of irr No� OCCUPANT LOAD ? 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[_] GEOLOGY INSPECTION ❑ deemed revokedC3 No Knowl. Panic NOSDevices El CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 effectPARKING ' SPACES REQ'D PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM TO I am exempt from the licensing requirements 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 / PRESENT USE SIGN ATURE mess and Professions Code) OF BUILDING QT Y p ? FINAL APPROVAL Gl V Lic.or Reg.No Date �. NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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 ❑ I, as owner of the property, will do the work and the 4 5 8 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING # 00'0640 CONSTRUCTION LENDING AGENCY # 0 0 0 D a o I hereby_affirm that there is a construction lending agency t for the performance of the work for which this permit is issued (Sec 3097,Civ C> 0 a26-81 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, TOTAL FEE d hereby authorize representatives of this County to enter pon the bo a-mento d operty for Inspection purposes. SEE REVERSE FOR EXP ANATORY LANGUAGE Siture of Permittee Date I \YORKERS'COMPENSATION DECLARATION CE s4s(t t-sal MISCELLANEOUS APPLICATION I I ]teieby affirm 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 u • a ceftified copy thereof(Sec. 3800,Lab.Q. NG Policy No. Company FOR APPLICANT TO FILL IN BIJILDI ADDRESS SS ❑ Certified copy is hereby furnished % BUILDING 1 LOCALITY / ADDRESS 1 E Certified copy is filed with the county building inspection % LOCALITY CSI NEAREST EAR sr. department. �jITY ' Date Applicant NEAREST / DISTRICT NO GR P CONST`// CESSED BY CROSS ST s7� /7J/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (1 F COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO NO. (CIRCLE) STATE MAJOR SECOND LOCAL BL GG D (This Section need not be completed if the work Involved TRACT �C/ NO ON GS ON LOT USE ZONE SPECIAL CONDITIONS by the permit Is for one hundred dollars (5100) or less.) r C9s� USE OF SIZE OF LOT `j EXISTING BLDG. I certify that in the Derformance of the «ork for which this permit is issued, I shall not employ any person in any manner % OWNER so as to become subject to the Yvorkers' Compensation Laws. % MAIL OCCUPANCY GROUP 1 ADDRESS (.� I — Date -Y Dlicant1 p/ NOTICE TO APPLICANT If, after making this Certificate of % CITY ®l�Q�dj/jll.L� noL�Ot�J OCCUPANT LOAD _ Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- ❑ I with Comply with suc!i provisions or this -iermit shall be TRAILER USE I GEOLOGY INSPECT'ON No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION INSPECTION (� Panic Devices MI 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 Cull force and �I effect PARKING REO'D I I pROVID ED 5'A CES License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE y FiOM _O n I am e%empt from -fie licensing 'eauirements as I am a INSPECTOR'S m i licensed architect or a re^__istered nrotessional Lnaimder S1ZE OF No OF SIGN TORE ? acting in m} prote,sional caDacn,. (Section -051 Bus_ EXISTING 3LDG STORIES mess and Professions Code). FINAL APPROVAL Z- -4 PRESENT USE OF BUILDING bb7� v Lic or Reg No. Date = I HOME OIVNER-BLILDER DECLAR YTION NO OF EXISTING BUILDINGS ON LOT AND USE I{ I herebv affirm that i am exempt from the Contractors I License Law for the Colloit me reason 'Section 7031 ;. Busi- ness and Professions Code) No PARKING SPACES PROVIDED [, as owner of die property will do_the work Ind the structure is not attended or offered Cor ,ale Section " } 7044 Business and Professions Code) PROPOSED USE of BUILDING CONSTRLCTION LENDING AGENCY g 'flfE �, I liereby affirm that there is a construction lending agenev for the performance of the work for which this permit is issued(Sec 3097,Civ C 1 Lender's Name PROPOSED MAX. OCC Lender's Address PERMIT FEE 25.00 1 I certify that I lime read this application and state that the a �e mformauon is correct I agree to comply%%ith all County ISSUANCE FEE ° or antes and State laic s relating to building construction, and )rebv authorize representatives of this County to enter TOTAL FEE 25.00 ponto above mentionedpon above mentioned propert, for ifor inspection p irpose n SEE REVERSE FOR EXPLANATORY LANGUAGE % % (/ Date Sianotti—o{11 -^tittee