HomeMy Public PortalAbout9026 LAS TUNAS DR_Miscellaneous__ WORKERS'C'(,)biPENSATIONDECLARATION
CE 875 (11-84) M ISCELLANEOUS APPLICATION
CE 875
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.C) -
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING LOCALITY
XX• ADDRESS 026 E. Las Tunas br.
Certified copy is filed with the county building inspection LOCALITY Temple City NEAREST
department XXX CROSS ST
Date _Applicant NEAREST DISTRICT NO GROUP TYPE PR CESS ED BY
1 CROSS ST / // CONST.
CERTiI ICATE OF EXEMPTION FROM WORKERS' n � LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP HIGHWAY
no - (CIRCLE) STATE MAJOR SECOND LOCAL
1 NO. OF BLDGS
(rills 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
SIZE OF LOT EXISTING BLDG. (�
I certify that in the performance of the work for which this E- oza cmi y `_3
permit is issued, I shall not employ any person in any manneXX OWNER of building Pro 'ernes
�o as to heeonle suhlect M the Workers' Compensation Laws OCCUPANCY GROUP
_ ADDRESS P• 0• BOX 8246 C-,
r-
Date - -- --- APPlicant- -- - uI
NOiICE f0 APPLICANT If, after making this Certificate of CITY Newport Beach NOL 714 768 4033 OCCUPANT LOAD V3
Lxemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such ptovlsions, or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl. -
decmed revoked
LICLNSLD CON]RACIORS 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 anX r�I
effect Name of business PARKING REQ'D 1 I PROVIDED
LLJ IBJ
License Number Lie Class Accent On Dance/Broadway Costumes SPACES
LIMITED TIME USE
Contractor_ —Date DATE DATE
TO'
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer- SIZE OF No. OP (NSP oR s
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES s TURF
mess and Professions Code) FINAL APPR O V A L
PRESENT USE OF BUILDING - •-
Lie or Reg No Date
HOME OWNER-RLiILDER DECLARATION No of EXISTING BUILDINGS
ON LOT AND USEt-I•-1-
1 hereby affirm that I am exempt from the Contractor's -
License Law for the folloising reason (Section 7031 5, Busi-,
ness and Professions Code) NO. PARKING
I, 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)
CONS 1 RUCTION 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
Address
��,�t
I certify the r
l av T"' t i s ap IuUPERMIT FEE aon and state that the -
00
above infunna ion orrect I agr e to comply with all County ISSUANCE FEE
ordinances/nd ate law rela ng to building construction,
and/liereby au d e atrves of this County to enter TOTAL FEE 25 - 00
upon the'i ve-ii nti d perty for inspection p rpo s
SEE REVERSE FOR EXPLANATORY LANGUAGE
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