HomeMy Public PortalAbout9445 1/2 LAS TUNAS DR_Miscellaneous_1/25/2001_Honey Bee Bakery WORKERS' COMPENSATION DECLARATION '"NI4.1J MI:JGtLLAIYtI.IU- rAr-r—r_��..HI ,vry
20-0063DPW 12/90 /7
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 7IIf'ff
insure,.X a ceiir ficate of Workers' Compensation Insurance, or
a"certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company_ FOR APPLICANT TO FILL IN BUILDING,! _.eE
BUILDING.ADDRESS ADDRESS _
❑ Certified copy is herebv furnished. 1 9445 112 , Las Tunas Dr. LOCALITY
❑ Certified copy is filed with the county building inspection CITY ZIP NEAREST
department: Temple Citv CA 91780 CROSS ST.
Date Applicant_ SIZE OF LOT - NO.OF BLDGS."NOW ON LOT DISTRICT NO. GROUP TYPE / P SSED BY
-__ O r/ CONST.
CERTIFICATE OF EXEMPTION FROM:WORKERS' TRACT BLOCK LOT NO. [! ///CCC7���
COMPENSATION INSURANCE MAP HIGHWAY
NO. .(CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
b*the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this OWNER Harry Harry Gewertz
permit is ecome shall not employ any person in any manner
so as to'become subject to the Workers' Compensation Laws. ADDRESS OCCUPANCY GROUP
533 14th Street
Date Applicant CITY ZIP
:;NOTICE TO APPLICANV If, after making this Certificate Santa Monica CA 90402 OCCUPANT LOAD
of'Exemption; you should becomesubject subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE:
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Kno'wl. ❑
revoked.
OCCUPANCY INSPECTION❑ Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW)
9(commencing with Section 7000)of Division3 of the Business NO.OF EXITS
and Professions Code,and my license is in full force and effect.
PARKING• REQ'D D PROVIDED D
License Number Lic. Class SPACES
Contractor Date LIMITED TIME USE
_ DATE DATE
I am exempt from the licensing requirements as 1 am a FROM: TO:
licensed architect or a `registered professional engineer INSPECTOR'S
-actin in m professional capacity (Section 7051,Business _SIZE IN NO.RI SIGNATURE
g y p EXISTING BLDG. STORIES
and Professions Code).
LIC. or Reg. No. Date .PRESENT USE OF BUILDING FINAL APPROVAL
none -ye
HOME OWNER-BUILDER DECLARATION No.of EXISTING BUILDINGS
ON LOT AND USE _
".l hereby affirm that 1 am exempt from the Contractor's License
'Law for the following reason (Section 7031.5, Business and
Professions Code): NO.PARKING
SPACES PROVIDED
rI 1
❑ I,,as owner of the property, will do"the work and they . .
structure is not intended.or offered for sale(Section 7044X PRO POSED USE OF BUILDING -
Business and Professions Code).
CONSTRUCTION LENDING AGENCY - Bakery
I hereby affirm that there is a construction lending agency for Y
the performance'of the work for which this permit is issued I
(Sec. 3097, Civ: C.). PROPOSED MAX.occ.
Lender's Name-- APPLICANT(PRINT) TEL No.
Yun-Baw Lin
Lender's Address ADDRESS
I certify that I have lead this application and state that the P
above information is correct. I agree to comply with all County I:PERMIT FEE -
ordinances and State laws'relating to building construction,and
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentioned property for inspection purposes:
TOTAL FEE
X 10 ,>00 SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Dat