HomeMy Public PortalAbout9001 LAS TUNAS DR_Miscellaneous__ - WORKERS'COMPENSATION QECLARATION
CE 875 111-84) MISCELLANEOUS APPLICATION
CE 875 ifl
1 hereby affirm that I have a certificate of consent to self NTY OF-LO° A,NGELEf I30ILDING AND SAFETY DIVISION
' insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). i
Policy No. Company -" —..FOR APPLICANT TO FILL IN BUILDING a +�/j' 1
_-_-��` ADDRESS I��j �•� /�S l�{�1.�3 ��,-
Certified copy is hereby furnished. XX BUILDIN ADDRESS C l�l/�- S ?��jysF,; ./M� -/" I e cT
LOCALITY
Certified copy is filed with the county building inspection LOCALITY,
.�•� h NEAR ES7
department. XX re.Mti1 LAC v CR0 IS ST. 41 e,
Date Applicant NEAREST CRO85 ST. s��-A-� -�DISTRI T NO. GROUP NST TYPE CESSED BY
�65�/t' O /� CO
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF /
1 certify that in the performance of the work for which this
SIZE of Lor tExlsnrJG BLDG. 0-
permit is issued, I shall not employ any person in any manne X OWNER of buildin Cou%hP Q •'lle-A 1162
so as to become subject to the Workers' Compensation Laws. MAIL �y� OCCUPANCY GROUP
N(✓Ijj F� C�-.��•- �•
Date ADDRESS CJ
Applicant era TEL. 7 L`I
OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITYtqQyy &- hSeA& .41244c 6,qv- lt6,0 v3
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 this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 anix
effect. Name of business PARKING REQ'D PROVIDED
srwcEs II �l=L�—_CJI
License Number Lic. Class AMt �AP_6&
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from t11e licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. b 5,� STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg. No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE �-
I hereby affirm that I am exempt from the Contractor's 4J
License Law for the following reason (Section 7031.5, Busi-
ness
usi ness and Professions Code): • NO. PARKING ^�
El1, as owner of the property,-will do the work and the SPACES PROVIDED
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 agencye I I VI
for the performance of the work for which this permit is
CO t�t
issued(Sec. 3097,Civ.C.).
Lender's Naine M;
PROPOSED MAX. OCC. 1=1 :¢11
Lender's Address------
^I�
PERMIT FEEfir+ 1`1
I certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25- 00
upon ti ve-mentioned prop rt y for inspection purposes. �•
XX (!� XX /4--q-7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date