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Home My Public Portal About9644 LAS TUNAS DR_Miscellaneous__ i WORKERS'COMPENSATION DECLARATION ! CE 875 M I S C E L LA 9�E®� APPLICATION 1 CE 875 (2-80) I hereby affirm that I have a certificate of consent to self COUN'T'Y OF LOS ANGELES BUILDING AND SAFE'T'Y DIVISION insdre,or a certificate of Workers'Compensation Insurance, a certified copy thereof(Sec.3800,Lab.C.) Ir Policy No. Company BUILDING ADDRESS [/ FOR APPLICANT TO FILL IN ADDRESS 7 nkQJ ❑ I r Certified copy is hereby furnished. � BUILDING /` LOCALITY ADDRESS C•/ EJCertifiedcopy is filed with the county building,inspectior DEAREST department. LOCALITY f clRoss ST. / r Date ApplicantEAREST "IS TRICT��wN111O. :;0 P TYPE PR 5E BY 4 CROSS ST. atm '�` hV �, CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �u/a COMPENSATION INSURANCE { DESCRIPTION LOT NO. BLOCK NAP �(%07 H'H E) STATE MAJOR SECOND CAL NO. OF BLDGS. LL (This section need not be completed. if the work Involve('. TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($1.00) or less.) use OF //]1 0 SIZE OF LOT EXISTING BLDG. I I certify that in the performance of the work for which thil V cc cc permit is issued, I-shall not employ any person in any manne>' WNER _ I so as to become subject to the Workers' Compensation Laws4. O ` i ' OCCUPANCY GROUP AIL ADDRESS p ,� /S�' �'r Date Applicant V) NOTICE TO APPLICANT: If,' after making this Certificate of; CITY No� �j 7 OCCUPANT LOAD Exemption, you should become. subject to. the Workers'1 APPLICATION FOR I EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth-: It with comply .with such provisions or this permit shall beI ❑ ❑ No Spec. Knowl. ❑ TR AILER,U SE GEOLOGY INSPECTION �. deemed revoked. � Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter! SAFETY PERMIT Q ,(LIST ITEMS BELOW) 9 (commencing with Section 7000)of Division 3 of the Busi- No. of Exlrs ness and Professions Code, and my license is in full force and ' PARKING. effect. sP�kCES REO'D PROVIDED License Number tic.Class LIMITED TIME USE Contractor Date ' DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a 1 licensed architect or a registered professional engineer SIZE OF NO. OF I INSPECTOR'S acting in my professional capacity (Section 7051, Bus- I EXISTING BLDG. STORIES SI NATURE iness and Professions Code). iFINAL APPROVAL /y ESENT USE OF BUILDING U Lic.or Reg.No. Date NO. OF EXISTING BUILDINGS ' HOME OWNER-BUILDER DECLARATION f ON LOT AND USE � I hereby affirm that- I am exempt from the Contractor's 1 I, License Law for the following reason (Section 7031.5, Busi-' ness and Professions Code): No. PARKING SPACES PROVIDED 4:2 1.� r/ ❑ I., as owner of the property, will do the work and the o 0 0 0 0 �Qfl z structure is not intended or'offered for sale (Section 7044, Business and Professions Code). OPOSED USE OF BUILDING 2. 1 1 —8 4 CONSTRUCTION LENDING AGENCY I hereby affirm that 'there is a construction lending agency for the performanceof the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE o J 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 J 1, ordinances and State laws relating to building construction, TOTAL FEE _ �a andel/// - he au orize representatives of this C unty to enter 1 ®D n t mention pr erty ins ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee D to WORKERS'COMPENSATION DECLARATION CE 875(11-84) 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.). BUILDING Policy No. Company FOR APPLICANT TO FI LL IN ABLEESSSS ADDR FlCertified copy is hereby furnished. BUILDING . UN S ADDRESS,. LOCALITY Certified copy is filed with t e county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DI 1 GROUP TYPE PRO SSED CROSS ST. � �• CONST. CERTIFICATE OF EXEMPTI N FROM WORKERS' LEGAL COMPENSATION I SURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND OCAL NO. (CIRCLE) I NO. OF BLD GS. (This section need not be compl ted if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CON IT IO NS by the permit is for one hundre dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. 4 I certify that in the performance o the work for which this permit 1's issued,I shall not employ ny person in any manner OWNER t S� so as to become subject to the Wor ers' Compensation Laws. MAIL ` OCCUPANCY GROL Njillap Date Applicant ADDlxess f•, cs pp TEL' OCCUPANT LO D w NOTICE TO APPLICANT: If, after aking this Certificate of CITY No. a y Exemption, you should become bject to the Workers' Compensation provisions of the Lab r Code,you must forth- APPLICATION FOR EXIT HARDWARE: _ With comply With such provisions r this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Kn W. deemed revoked. Panic Device LICENSED CONTRACTORS ECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed and r provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of rvision 3 of the Busi NO. OF EXITS ness and Professions Code,and my lice se is in full force and � ,� ` effect. e— PARKING SPACES REQ'D PROVIDED License Number Lic. C1 ss LIMITED TIME USE ContractorDate DATE DATE El FpOM: TO: I am exempt from the licensing reo irements as I•am a / licensed architect or a registered rofessional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING / Lic.or Reg.No. ate HOME OWNER-BUILDER DEC ARATIO& NO. OF EXISTING BUILDINGS O E ON LOT AND usE - I hereby affirm that I am exempt fr in the Contractor's License Law for the following reason ( ection 7031.5 Busi- ness and Professions Code): NO. PARKING Socio_II] v 16/9la SPACES PROVIDED El I, as owner of the property, will o the work and the 1 2421 1 i;0. ?0.35 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED 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.Q. 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 corptruction, and hereby authorize representat' es of this Coun to it TOTAL FEE upon the abov -mentioned per .or inspection ur to es. SEE REVERSE FOR EXPLANATORY LANGUAGE T ` ' ignature of ermit ee Dat