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Home My Public Portal About9614 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION I SC E L LA p�gI� EO U S APPLICATION .-' .,, CE CE 875 875 (11-84) 1 hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APP LICANTTO FILL IN BUILDING ADDRESS Certified co is hereb furnished. uILDING py y DDRESS .d" / LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY `� NEAREST department. G T cRoss sr. Date Applicant NEARESTDISTRI LNO .GROUP TYPE P ESSED B CROSS ST. CONST Y '�— � //r O� � CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL l^ COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK 91 J MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT �fjsfp NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF s �g SIZE OF LOT ` EXISTING BLDG,/ j /J I certify that in the performance of the work for which this permit is issuedI shall not employ Q J o p , p y an y person in any manner owNER D.� V(A� afA •�� so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP ADDRESS /4f,,9 U Date Applicant LL! TEL' O_ NOTICE TO APPLICANT: If, after making this Certificate of CITY C. NO. � OCCUPANT LOAD y3 Exemption, you should become subject to the Workers' Iz Compensation provisions of the Labor Code,you must forth- APPLI &TION FOR EXIT HARDWARE: with comply with such provisions oI this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. El deemed revoked. LICENSED CONTRACTORS DECLARATION occuPANcv 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 1/ effect. NAM- 6-,P 14SI Ness PARKING 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 / SIGNATURE /f iness and Professions Code). < ` �A�� FINAL APPROVAL PRESENT USE OF BUILDING hvw Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. of EXISTING BUILDINGS y Z C ON LOT AND USE - 1 hereby affirm that I am exempt from the Contractor'st License.Law for the following reason (Section 7031.5, Busi ftp fIfcWe 00101—�l01I1 4/i,21/93 ness and Professions Code): NO. PARKING5�. � 1 PM ,::e I, as owner of the property, will do the work and the SPACES•PROVIDED 9176 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY ROPOSED USE of BUILDING 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 ` I certify that I have lead this application and state that the PERMIT FEE 6O above information is 16nrect.I agree to comply with all County ISSUANCE FEE ordinances and St e ws relating to building construction, and hereby autho Ize epresentatives of this County to enter TOTAL, FEE QD upon t ov en oned pro rty fo.,inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of PermittewIF Date WORARS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C A T I O N o I heiebaffirm that I have a certificate of consent to self CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a;czatificate of Workers'Compensation Insurance,or a certified copy therzof(Sec. 3800,Lab.C.). Policy No l•i� Company FOR APPLICANT TO FI LL IN ABUILDING DDRESS ti , BUILDING ❑ Certifieu c is hereby furnished. ADDRESS LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITYNEAREST �y department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P SSED BY CROSS ST. /�4rii O� .L CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. /5b (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 ($100) or less.) USE of ,/r7 SIZE OF LOT EXISTING BLDG. 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' Compensation Laws. MAIL OCCUPANCY GROUP /3 y C3 ADDRESS t . ♦ .Z-• Date Applicant W TEL' NOTICE TO APPLICANT: If, after making this Certificate of clrYOCCUPANT LOAD 0- r_ No. C115Exemption, 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ❑ deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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 REq D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF ND- OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 45IGATURE iness and Professions Code). T USE OF BUILDING FINAL APPROVAL ` /�" ` RESEN / �JU 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 ElI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). �(t�♦ 553.8A CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # • o o • 8 8 1 hereby affirm that there is a construction lending agency o 0 0 0 0 0,a for the performance of the work for which this permit is '� cn issued(Sec. 3097,Civ.C.). 0 1 O `$6 Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State la lating to building construction, and h reby authorize pre ntatives of this Cou ty to enter TOTAL FEE upo �U" mei ne roperty for inspect' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ��nure of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I hVeby 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 a certified copy thereof(Sec. 3800,Lab.C.) Policy No.' Company FOR APPLICANT TO FILL IN BUILDING J ADDRESS ❑ Certified copy IS hereby furnished. ADDRESS / , ��e• LOCALITY ❑ Certified copy is filed with the county building inspection ^` NEAREST department. ocwLITY �e ��, cRoss ST.' Date Applicant EAREST J DISTRICT tl,Q. �UP TV E PR C SSED BY CROSS ST. (_,�` �,/�� (/Jl(VA/ CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO'. BLOCK MAP HIGHWAY STATE MAJOR SEC NO LOCAL NO. (CIRCLE) tZ NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT ]USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this �y� O permit is issued, I shall not employ any person in any manner OWNER �/ ///tfSfC ~ so as to become subject to the Workers' Compensation Laws. MAIL � OCCUPANCY GROUP .7 _ W DDRESS� ✓�- tl Date Applicant to NOTICE TO APPLICANT: If, after making this Certificate of ITY�` NoL - p OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APP KATION FOR EXIT HARDWARE: with comply with such provisions Or this permit shall be TRAILER USE 0 GEOLOGY INSPECTION No Spec. Knowl. ❑ deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONPA I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT I (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 PARKING effect. SPACES REO'D D PROVIDED License Number Lic.Class LIMITH—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 S GNATUR iness and Professions Code). FINAL APPROVAL PliESENT USE OF BUILDING i Lic.or Reg.No. Date 4 a e NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION !9299.2A ON LOT AND USE # O ® 0 0 8 8 I hereby affirm that, I am exempt from the Contractor's In License Law for the following reason (Section 7031.5, Busi- 0 0 0 0 0 0 o z NO. PARKING ' ness and Professions Code): ACES PROVIDED 09.24-, 85 F-1 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 67!. K//Y �� /�'— 1t )e6A LC 7044, Business and Professions Code). n PROPO ED USE OF BUI DING CONSTRUCTION LENDING AGENCY ,,p�� I hereby affirm that there is a construction lending agency 1 DE Cllr. C ",0RI e,s S for the performance of the work for which this permit is J issued (Sec. 3097,Civ.C.). has-� t l C ,� Lender's Name PROPO1.Eb MAX. OCC. Lender's Address PERMIT FEE �Ct 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 t above-ment' ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ature of Permittee Date