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Home My Public Portal About9070 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION 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 LD' LOCALITY DD ESS 9070 Las Tunas ,Drive ❑ Certified copy Is filed with the county building mspection NEAREST department. cALITY Temple City, CA 91780 CROSS sT Date Applicant AREST DISTRICT NO. G OUP TYPE PRO SED BY , ROSS ST sultana CONST 1 / CERTIFICATE OF EXEM'PTION FROM WORKERS' LEGAL {/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAV >_ NO (CIRCLE) STATE MAJOR SECON LOCAL IL NO OF BLDGS (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 ($100) or less.) USE OF SIZE OF LOT - EXISTING BLDG ,v ,cc 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 2>P19R John Waade/Waade Realty Co. U so.as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP17W MKEss907O Las Tunas Drive y CL TEL Date Applicant Z NOTICE TO APPLICANT If, after making this Certificate of ITYTemple Cityr NO818 309-9.345 OCCUPANT LOADi 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 El 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 Buso- NO. OF EXITS ness and Professions Code, and my license is In full force and PARKING. effect - SPACES REQ'D PROVIDED License Number Lie Class LIMITED TIME USE Contractor Date - DATE DATE FROM To I am.exempt from the licensing requirements as I am a El licensed architect or a registered professional engineer SIZE OF No OF INSPECTOR'S acting in my professional capacity,(Section 7051, Bus- EXISTING BLDG. STORIES 1 P!,C.NATU5E mess and Professions Code). 1 PHESENT USE OFINAL APPROVAL F BUILDING Lw 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 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code) NO PARKING O 1 2 1 SPACES PROVIDED 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code) P001rOSED USE of BUILDING CONSTRUCTION LENDING AGENCY 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 l PERMIT FEE I certify that I have read this application and state that the above Information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize represe ati es of this County to enter TOTAL FEE the above-me a erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 1-8-85 Signature of ermittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby a certificate 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 Company FOR APPLICANT TO FILL IN BUILDING ADDRESS D ADDRESS aim Certified copy is hereby furnished. UILDING ADDRESS LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS sT. Date Applicant AR EF7E: ST DISTRICT NO. TYPP ESSED BY CROSS ST. Ccorvsr. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP /� �[ b�IIGMWAY RD./�-�/'�w(CIRCLE) STATE MAJOR SECOND L AL L� NO. OF BLDGS. (This section need not be completed if the work involved TRACT Vim/ NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. o permit is issued, I shall not employ any person in any manner ZI..NER C' so as to become subject to the Workers' Compensation Laws. IL OCCUPANCY1GROUP �"_L o ADDRESS t Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ITY NO. 8,S—, OCCUPANT LOAD a Exemption, you should become subject to the Workers' APPLIC TION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. ❑ E] 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 D SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a 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 SIGNATURE iness and Professions Code) S ENT usE of BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION F EXISTING BUILDINGS AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 5 3 4,2 A 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING A6 # • o o ! 88 I hereby affirm that there is a construction lending agency �J 1 0 0 0 0 • e o, for the performance of the work for which this permit is issued(Sec. 3097,Civ Q. X Lender's Name 0 (192-86 PROPOSED MAX. OCC. 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 hereby authorize representatives of this County to enter TOTAL, FEE up n the above- enti ned pro erty r inspec on purposes SEE REVERSE FOR EXPLANATORY LANGUAGE natureo er ttee Dat WORKERS' COMPENSATION DECLARATION 410I4� IVII.�. (.ItLLHIVC.VU.7 /-�C-Irl_IVHI 1VIV 20-0063DPW 12/90 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 9Q �Q G ADDRESS Certified copy is hereby furnished 17W'70 LOCALITYCertified copy is filed with the county building InspectionCITY ZIP department Q / , NEAREST Date Applicant SIZE OF LOTNO.OF BL GS NOW ON LOT DISTRICT NO GROUP TYPE P ESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' 1,4 CONST COMPENSATION INSURANCE TRACT BLOCK LOT NO ///�� MAP HIGHWAY NO ICIRCLHI STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS by;,the permit is for one hundred dollars ($100) or less.) for which this 1 certify that in the performance of the work OWNER T NO. any person In any manner permit is Issued, I shall not employProperty 7-75 ; so as to'become subject to the Workers' Compen ation Laws ,4DDRESS OCCUPANCY GROUP Date 6-/1-17-0 Applicant 1 ctry . ZIP ;NOTICE TO APPLICANT If, a er makl g this Certificate OCCUPANT LOAD `bf Exeinption, you shouldbecome subject to the Workers' APPLICATION FOR Ea'IT HARDWARE Compensation provisions of the Labor Code,you must forthwith •comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ )LIST ITEMS BELOW) NO OF EXITS 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect. PARKING: REq•D D PROVIDED D License Number Lic Class u SPACES Contractor Date LIMITED TIME USE -; , S - DATE DATE 5❑�'I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE NO INSPECTOR'S acting in my professional capacity (Section 7051,BllSlneS$ EXISTING BLDG STORIES SIGN RE I and Professions Code) Lic. or Reg No. Date PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NOOF EXISTING BUILDINGS ON LOT AND USE '1 hereby affirm that 1 am exempt from the Contractor's License i -Law for the following reason (Section 70315, Business and Professions Code): INO PARKING El1, as owner of the property, well do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044.E PROPOSED USE OF BUILDING Business and Professions Code). l tJ2 CONSTRUCTION LENDING AGENCY 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) PROPOSED MAX.OCC Lender's Name APPLICANT(PRINT) TEL NO Lender's Address ADDRESS I certify that I have read this application and state that the ' above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE 'the of:ove-mentioned property for Inspection purposes rt ^ TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE Slgniture of Perrfittee y Date 1,