HomeMy Public PortalAbout10816 DAINES DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION '` 76M444 �-
r -" CE 875 (2-80) MISCELLANEOUS APPLICATION .
I hereby affirm that I have acertificate of consent to self t 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. CompahyBUILDING
FORAPPLICANT TO FILL IN ADDRESS ,G
❑ Certified copy is hereby furnished. BU.ING - - LOCAurY
AOO KESS G
NEAREST
Certified copy is filed with the county building inspection. -.
department LOCALITY Temple City - cRoss sr. _
Date Applicant 1 NEAREST DISTRICT NO GROUP TYPE PRO SSEO BY
CROSS Sy- Between Welland & McCulloch _ 3,off` =DN -
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL.
COMPENSATION INSURANCE, _ DESCRIPTION LOT No. BLocic �] /, ,,,UHWAY
MpPadS� (CIn CIE) STATE MAJOR SECOND LOCAL
NO. OF BLOGS. rvD d
(This section need not be. completed'if the work involved TRACT - NOW ON LOT "1 USE ZONE SPECIAL CO NOITIONS O
by the permit is for one hundred dollars ($100) or less.) USE of U
' Ir
1 certify that in the performance of the walk for which this SIZE OF LOT59.67X159.951 EXISTING BLDG.ReS dent
permit is issued, I shall not employ any person in any manner owrvER John & Lynne Burkardt �O
so as to.become subject to the Workers' Compensation,Laws. MAIL OCCUPANCY GROUP U
LU
ADDRESS Same a
Date ' Applicant N
NOTICE TO APPLICANT: If, after making this Certificate of CITYoL3.rJp-3266 OCCUPANT LOAD. Z
Exemption, you should -become subject to the Workers' -
Compensation provisions of the Labor Code, you must.forth, APPLICATION FOR EXIT HARDWARE: ,
with comply With such provisions Or this .permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked. - ❑ ❑ No Spec. Knowl. El
LICENSED CONTRACTORS DECLARATION OCCUPAN.CY INSPECTION .Panic'Devices ❑
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 ,
ness and Professions Code, and my license is in full force and .
effect. } lease check Kitchtn Bath gr Centr.91 PARKING
SPACES REO'.O E= PFOV) ED
License Number Lic.Class Air Conditioning & Water
Heater LIMITED TIME USE
Contractor Date ' E DATE
F1I am exempt from the licensing requirements as 1 am a. - - ro
licensed architect or a registered professional.engineer SIZE OF No. OF INSPELCTOR'S
acting in my professional capacity (Section 7051,'Bus- EXISTING BLDG. - 1pl3 S f sroRres / e-v �0 s-SG rvJf U
iness and Professions Code). _ FINALA PROVAL
PRESENT USE OF BVILDING Residence
Lic.or Reg.No. Date
HOME OWNER:BUILDER DECLARATION NO, OF NG2872
'BouolNGs 9A
AND U '
ON LOT AND USE
1 hereby affirm that I am, exempt from the Contractor's to inspectproperty I please. contact. -
License-Caw for the following reason;(Section 7031.5. Busi- - ,2 e ° 80,•50
ness and Professions Code): -
Charles Powers 287-1141% 25--9471
1; as owner of the property;will do the work and the °,°,° 80.0 pv
structure is not intended or offered for sale (Section '
7044, Business and Professions Code). O 2 0 b 84
PROPOSED USE OF BUILDING - -'- • •
CONSTRUCTION LENDING AGENCY -
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 '
r PROPOSED MAX. DEC. -
Lender's Address PERMIT FEE a/ I
I certify that 1 have read this application and state that the -
above information is correct. I agree to comply with all County
ISSUANCE Fee ' a
ordinances -and State laws relating to building construction, TOTAL FEE
and hereby authorize re resenI.tives of this Co my to enter V '
opo the above-menti If proper v for in ec on purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE-
ary 6, 1984
Sijstare of Permittee Date
F.