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Home My Public Portal About9655 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 U insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company BUILDING --� FOR APPLICANT TO FILL IN ADDRESS (0 5 NIBS ❑ Certified copy is hereby furnished. 'ADDRESS (Q UILDING / � I LOCALITY EJ Certified copy is filed with the county building inspection NEAREST .9--/department. LOCALITY G CROSS ST. Date Applicant NEAREST ' DISTRICT NO. GROUP TYPF PROC SSED BY CROSS ST. - �x1 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v DESCRIPTION LOT NO. BLOCK9L45O� Ov ) STATE MAJOR SECOND LOCAL d COMPENSATION INSURANCE / NOP (7 ci c eY } (This section need not be completed if the work involved NO. OF LOT USE ZONE SPE IAL CONDITIONS U P TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less.) U USE OF SIZE OF LOT oo S , 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 manner J�WNE.JOAV f�NINP so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP Q�a.� W ADDRESS. ` (L Date Applicant to TEL. z NOTICE TO APPLICANT: If, after making this Certificate of CITY No. —I OCCUPANT LOAD ExemptCompensation you should become subject , 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 0 GEOLOGY INSPECTION deemed revoked. NO Spec. Knowl. ❑ Panic Devices ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION [a/ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO. OF EXITS 9 (comrhencing with Section 7000)of-Division 3 of the Busi- ness and Professions Code, and my license is in full force and Pq RKINc. effect. � • REO'D E= PROVIDED �1✓ SPACES License Number Lic.Class LIMITED TIME USE Contractor Date W.40S ..TF DATE ❑ : I am exempt from the licensing requirements as 1 am a FROMTO: licensed architect or a registered professional engineer SIZE OF �S,.�C} NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. (C//(V/ STORIES SIGNATURE Iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date S HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE r 0 2 1.7 (I 1 hereby affirm that, I am exempt from the Contractor's G l Y License Law for the following reason (Section 7031.5, Busi- # • • • • 8 8 ness and Professions Code): No. PARKING SPACES PROVIDED I, as owner of the property, will do the work and the � ID , z structure is not intended or offered for sale (Section 7.06-81 7044, Business and Professions Code). PROPOSED USE OF BUILDING 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.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above informat' ' orrecIt I agree to comply with all County ISSUANCE FEE ordinanc nd S • e la relating t b '1 'ng construction, and reby a ize r ese ,ti v o County to enter TOTAL FEE ' ^�Q ov me r p t r ection urposes. GF REVERS FOR tXPLANATORY LANGUAGE Sj n• re of Per ' t Date WORKERS'COMPENSATION DECLARATION E 875 (2-80) CMISCELLANEOUS APPLICATION CE 875 c� p I hereby affirm that I have certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '1LJfl insure, or a certificate of Workers'Compensation insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company— FOR APPLICANT TO FILL IN ADDREJ ❑ Certified copy is hereby furnished. — BuILDING A(� LOCALITY e AD DRESS gb�fs ❑ Certified copy is filed with the county building inspectionNEAREST department. LOCALITY 91_J 160 CROSS ST. Date Applicant NEAREST DISTRICT NO. G UP TYPE PROC SSED BY CROSS ST. /` CONSJ/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 0 v COMPENSATION INSURANCE DESCRIPTION LOT NO. C3 BLOCK MAP MIGKWAY } rvo. A 6 (CIRCLE) STATE MAJOR SECOND LOCAL � NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0 by the permit is for one hundred dollars ($100) or less.) USE CrSIZE OF LOT EXISTITI NG BLDG. I certify that in the performance of the work for which this 0 permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP r� ADDRESS 11 Date Applicant tr7 NOTICE TO APPLICANT: If, after making this Certificate of CITY 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 INSPECTIONNO Spec. Knowl. ❑ deemed revoked. Panic DevicesE]CONTRACTORS DECLARATION occuPwrvcY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (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 effect. PARKINGSPACES REO'D 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 t / NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. too x STORIES j SIGNATURE iness and Professions Code). „ /� FINAL APPROVAL 7— �/ PRESENT USE OF BUILDING v �3 Z J4.J Lic.or Reg.No. Date NO. OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION �{ 1 5 4 A ON LOT AND USE # I hereby affirm that I am exempt from the Contractor's y 0 z License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 0 223-81 SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). f. PROPOSED USE OF BUILDING yO� CONSTRUCTION LENDING AGENCY /�� 1 I hereby affirm that there is a construction lending agency k4, for the performance of the work for wJtich this permit is issued(Sec. 3097,Civ.C.). Lender's Name - PROPOSED MAX. OCC. Lender's Address PERMIT FEE 1 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 and her rrE ize r ntatives of this County to enter upon h nti d roperty for i ec ton purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Q-- 13 _�591- Signature of Permittee Date Y I 1