HomeMy Public PortalAbout8812 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 675 (2-60) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent IO self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensatinn Insurance,or
a certified copy thereof(Sea 3800, Lab.C.)
Policy No. Company FOR APPLICANT TO FILL INBUILDING
F-1 'ADDRESS O ,
Certified copy is hereby furnished. uuolNG LOCALITY
ADDRESS m
Certified copy is filed with the county building inspection
department. Lo ^CITY San Gabriel, Ca. 91776 - NEARESTCROSS ST.
Date ApplicantWEARIEST DISTRICT NO. GROUP TYPE PROCE..EO BY
CROSS ST. _Muscatel O� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. eLocX :P ,GRWA -
(CIRCLE) STATE MAIOR SECOND LOCAL a
NO. OF BLOG3.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars (SIOO) or less.) . USE OF "/O
SIZE OF LOT EXISTING BLDG. J ac
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 wNER (. f—
so as to become subject to the Workers',Compensation Laws. AIL OCCUPANCY GROUP W
ADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY -South El MonteNo` 444-5569 Bus. OCCUPANT LOAD 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 or thispermit shall he TRAILER USE(:] GEOLOGY INSPECTION
KnowL ❑
deemed revoked. No Spec. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
of A:CL SPACES PARKIREO•D O PROVIDED D
License Number Lic. Class
. , LIMITED TIME USE
CLjitractor Date DATE AT.
I am exempt from the licensing requirements as I ama.
licensed architect or a registered professional engineer SIZE OF NO, OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. sTORIEs sIGNwTURE
iness and Professions Code). 11`1R'ESENY USE OF BUILDING Show room & office FINAL APPROVAL
Lic.or Reg.No. Date—
HOME
ate HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSON LOT AND USE -
:8363A
I hereby affirm that- I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- 4, e • s 8 8
ness and Professions Code): NO. PARKING I
El1,
PROVIDED
I, as owner of the property, will do the work and the . ... e o E E z
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
RO POSED VSE OF BUILDING qhow room office
CONSTRUCTION LENDING AGENCY
1 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
-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
ordinance and State laws ��Isting [o ding construction, TOTAL FEE
and he authoriz rep entatives this County to enter
upo above-ry ti prop f r insp/ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ ✓ 1/19/84
Sig aPer ittje Date _