HomeMy Public PortalAbout9126 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76 44 (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.)
PolicyNo. Company--- BUILDING /�
P FOR APPLICANT TO FILL IN ADORES.
a Certified copy is'hereby furnished. I AltILDING 9126 Las Tunas Drive LOCALITY
ADDRESS
Certified copy is filed'with the county building inspectionNEAREST
department. LOCALITv Temple City, Calif CROSS ST. fy„�✓
Date Applicant IAREST DISTRICT NO. UP TYPE PROC SSE.D B
CROSS ST.
�� CONS,T.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL � VT 07 -
DESCRIPTION LOT NO. BLOCK MAP / HIGHWAY
COMPENSATION INSURANCE l/� STATE MAJOR SECOND LOCAL
This section need not be'com leted if the work involved NO. OF BLD S. "D. (CIRCLE) d
' ( p TRACT � NOW ON LOTUSE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF � 0'
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. cc
8
.permit is issued, I.shall not employ any person in any manner NER'Randolph G. Wilbur F-
so as to become subject to the Workers' Compensation Laws. IL OCCUPANCY GROUP
ADDRESS P.O. Bo X- A LLI
Date Applicant 222 8O 4 Cn
Temple Cit TEL' V 3 OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this.Certificate of rY p., Y No. e
Exemption, you should become subject --to the Workers'
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 a GEOLOGY INSPECTION No Spec. Know[. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS a
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. PARKING
SPA CES
REq'D O PROVIDED D
License Number Lic.Class LIMITED TAME USE'
Contractor Date DATE • DATE
.. FROM: TO:
�. I am exempt from the 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. STORIES SIGNATURE
iness and Professions Code). OfficeFINAL APPROVAL
SENT 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
License,Law for the following reason .(Section 7031.5; Busi-
NO. PARKING
nProfessions
Z 4 31.5'A
eSs and PI'OfeSsl OrIS Code): SPACES PROVIDED - -
I, as owner-of the property, will do the work and the
structure is not intended or offered for sale (Section # o 0 o 0 8 8
7044., Business and Professions Code). Distribution Of
n
ROPOSED USE OF BUILDING
O i O O O O O 0.Z
CONSTRUCTION LENDING AGENCY Paper Products I hereby affirm that there is a construction lending agency 0-609-82
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
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, TOTAL FEE
and hereby authorize representativesof this County to enter
IT"Ir hea ove- pro fqr insp purposes. SEE REVERSE fOR E HPLANATORY LANGUAGE
vb .7_gl
nature Permittee Date