HomeMy Public PortalAbout9221 FLAHERTY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
1 hereby affirm that I have a certificate of consent tself COUNTY OF.LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS /
FICertified copy is hereby furnished. BUILDING 9221 lR]ClI. Flaherty Street LOCALITY
ADDRESS
Certified copy is filed with the county building inspection LOCALITY
NEAREST
department. Temple City CROSS ST. [�
Date Applicant NEAREST DISTRICT NO. G UP TYPE PROCESSED BY
CROSS ST. Fdlcinita C/ CONST, /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I D ' V
COMPENSATION INSURANCE DESCRIPTION LOT NO. Port. 3 BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SEGO LOCAL
r�O. OF BLOGS.
(This section need not be completed if the work involved TRACT Santa anita 1 ROW ON LOT 1 USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT G'7 X 120 EXISTING BLDG. — �
I certify that in the performance of the work for which this J I
permit is issued, I shall not employ any person in any manner OWNER Michael B. Roach/Cheryl L.Roach 00) y
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP FV31 z
MAIL
Date Applicant ADDRESS 9221 M Flahert Street C-3
TEL. 1.11
NOTICE TO APPLICANT: If, after makingthis Certificate of CITY NO. OCCUPANT LOAD
Temple Cit 309^03 z
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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION E] No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION QC Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 Of the Busi- SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. Aionr Cd a. V FI 12 a PARKING
SPACES REQ D D PROVIDED D
License Number Lic. Class 0
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a I
FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date }� n
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE oI
I hereby affirm that I am exempt from the Contractor's o 0
License Law for the following reason (Section 7031.5, Busi- e o D 8 Q 5'0 c2i
ness and Professions Code): NO. PARKING
E] 1, as owner of the property, will do the work and the SPACES PROVIDED 0,2rl "88
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.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
U
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE O`
ordinances and State laws re ti to building construction,
and h r by authorize esentati s of this County to enter TOTAL FEE i
upo above- en pr)Pert for inspection purposes.
/(��/ J, SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign t re of mittee Da O