The URL can be used to link to this page

Home My Public Portal About9630 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 7S 44 (2-80) MISCELLANEOUS A P P Yom.I`SAT I O �1 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAF'ET'Y DIVISION insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company I FOR APPLICANT TO FILL IN wcnRess ❑ Certified copy is hereby furnished. `UILDING V S .�� //�� LOCALITY ❑ ADDRESS /V�% 2� ell 41.1-11 Certified copy is filed with the county building inspection iNEAREST o department. L CALITY CROSS ST. Date Applicant NEAREST DISTRICT NO. G OUP TYPE PROC SED BY i CROSS ST. e`. CONST. /-� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE MAP r HIGHWAY No. 7�7(}� (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if file work involved NO. OF BLOGS. USE ZONE S ECTAL CONDITIONS P TRACT NOW DN LOT U by the permit is for- one hundred dollars ($100) or less.) USE of U SIZE OF LOT EXISTING BLDG. d cc I certify that in the performance of the work for which this ,/ v U permit is issued, I shall not employ any person in any manner V- d h N (.- so as to become subject to the Workers' Compensation Laws.' MAIL /�+) ] l a�/ OCCUPANCY GROUP • I LJJ DDRESS /�//�/J V�O NY• L, Date Applicant TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY l Mg X14 No. f 8�/ OCCUPANT LOAD Exemption, you should become subject to the Workers' i APPLICATION FOR EXIT HARDWARE: Compensation prodisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be I TRAILER useGEOLOGY INSPECTION deemed revoked. � E] ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑ I hereby affirm'that I am licensed under provisions of Chapter I SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ❑ - 9 (commencing with Section 7000)of Division 3 of the Busi- r_ss and Professions Code, and my license is in full force and e;fect. I PARKINSPACES G' REQ'D O PROVIDED D License Number Lic.Class 1 LIMITED TIME USE Contractor Date I DATE DATE ❑ 1 FROM: TO: a I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineerI OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7U51, BLLS SIZE.STING BLDG. STORIES SIGNATURE iness and Professions Code). iAL APPROVAL rr� 7 -1 RESENT USE OF BUILDING [� Lic.or Reg.No. Date lF v 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- nes:and.Professions Code I NO. PARKING SPACES PROVIDED 00 1 2 V6 A ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section #'o a o e 88 7044,Business and Professions Code). i ROPOSED USE OF BUILDING o a o a o 0 0 Zt CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency /f /tT(�/L /� L J 0'4'1 9-83 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). i Lender':Name_ PROPOSED MAX. OCC. Lender's Address PERMIT FEE S I certify that I have'read this application and state that the •I above information is correct.I agree to comply with all County I ISSUANCE FEE Kon ' ances and State laws relating to building construction, I TOTAL FEE hereby authorize representatives of this County to enter theove-mentioned property for i spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - Sin ure of Permittee Dadk WORKERS'COMPENSATION DECLARATION CE 875444 75(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. Company FOR APPLICANT TO FILL IN BUILDING ADDRESSell z& Certified copy is hereby furnished. UILDINGO -rq R LOCALITY ' ❑ AN N Certified copy is filed with the county building inspection NEAREST department. L CALITV CROSS ST. Date Applicant NEAREST DISTRICTNO. G OUP TYPE PROC SED BY CROSS ST. 1�. CONST.Ile— CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL A/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAPHIGHWAY >_NO. F BLDGS. / NO. Q (CIRCLE) STATE MAJOR SECOND LOCAL IZ (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE 5 ECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) U USE OF I E OF LOT EXISTING BLDG. I certify that in the performance of the work for which this G 0 permit is issued, I shall not employ any person in any mannerNER q F so as to become subject to the Workers' Compensation Laws. IL Q A OCCUPANCY GROUP �. U LU DRESS � H//%! L� O x/ 0- Date ApplicantN/ �/ TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate ofY 4 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 USEGEOLOGY INSPECTION deemed revoked. ❑ ❑ No Spec. Knowl. ION Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECT ❑ 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- r%ess and Professions Code, and my license is in full force and effect. PARKING SPACES REO'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE aI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer slzE of NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, BUS XIS TING BLDG. STORIES SIGNATURE iness and Professions Code). AL APPROVAL �" 1 RESENT USE OF BUILDING „ 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 SPACES PROVIDED O El 1, as owner of the property, will do the work and the 2 7.6 A structure is not intended or offered for sale (Section o 7044, Business and Professions Code). 8 8 ROPOSED USE OF BUILDING • e • • • • • In ,'.. CONSTRUCTION LENDING AGENCY p / ` / }s I hereby affirm that there is a construction lending agency /1 (�/L /� Lrc [ 0 4 1 9—8 3 ;' for the performance of the work for which this permit is f... 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 ord' ances and State laws relating to building construction, TOTAL FEE a hereby authorize representatives of this County to enter on the ove-mentioned property for i pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sin ure of Permittee D