HomeMy Public PortalAbout11026 GREEN TREE LN_Miscellaneous__ W&RKERS'COMPENSATION DECLARATION a
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 87
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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS 11026. Greentree Lane
Certified copy hereby is furnished. BUILDING Temple Cit
ADDRESS 6 Creep-tr-,Qp LOCALITY
FICertified copy is filed with the county building inspection LOCALITY NEAREST ive Oak
department. Temple Cit CROSS ST.
Date Applicant NEAREST DIST ICT N GRO P ITYPE PR SSED BY
CROSS ST. Live Oak /� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 7 -I (��� V
COMPENSATION INSURANCE DESCRIPTION LOT NO. bOO LmICl43 MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SE Np LOCAL
NOOF BLDGS.
(This section need not be completed if the work involved TRACT 43111 NO.W ON LOT 1 USFONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100), or less.) us OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER Daniel F. & Jenny
so as to become subject to the Workers' Compensation Laws. MAIL OCCU,PANCY'GROUP i3 0
ADDRESS
Santa Anita Avenue
Date Applicant r I,.,
Cl-
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. \8 1 8> 4 4 8�3 411 OCCUPANT LOAD
Exemption, you should become subject to the Workers' MQQ t ez
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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING REq'D D PROVIDED O
SPACES
License Number Lie. Class gazebo — spa LIMITED TIME USE
Contractor Date DATE DATE
r
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 2 SI NATURE
iness and Professions Code). home FINAL APPROVAL
PRESENT USE OF BUILDING �
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE _ �9 5 8,9'A
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- # o 0,0*0 3 0
ness and Professions Code): NO. PARKING double car garage
I, as owner of the property, will do the work and the SPACES PROVIDED ® �Q 5'0
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 0 0 6 $Q 5 0,5,
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
. J '2-88
I hereby affirm that there is a construction lending agency gazebo—Spa .'
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. none
Lender's Address
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
ordinances and State laws relating to building construction,
and herebyauthorize representatives of this County to enter TOTAL FEE
upo abo e ent' ned property for inspeCio .purer. E REVERSE FOR EXPLANATORY LANGUAGE
'rlie
ig ure of Permit Date