HomeMy Public PortalAbout9668 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
hereby affirms that I have certificate of consent self
insure, or a certificate of Workers'
rs'Compensation Insurance,
e,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. ILDING LOCALITY
ADDRESS �-•/f .-GV C_. -•� `'G'
Certified copy is filed with the county building inspection NEAREST
department. 66CALITY / L.IT �} CROSS Sr.
Date Applicant NEAREST !' C/. vDISTRICT NO./J GR P TYPE P ESSED BY
CROSS ST. //�j' CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (i If J
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY }
rvO. (CIRCLE) STATE MAJOR SECOND LOCAL tl
NO. OFLOT USE ZONE SPECIAL CONDITIONS V
(This section need not be completed if the work involved TRACT NOW ON Lor
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. Cr
I certify that in the performance of the work for which this _ Q
permit is issued, I shall not employ any person in any manner -OWNERJV bolI14
g F-
so as to become subject to the Workers' Compensation Laws. MAIL yns _ Q OCCUPANCY GROUP W
ADDRESS d
Date Applicant Z
I(olEL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD
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[:] 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 V (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. SPACES REO'D ==I PROVIDED O
License Number Lic.Class
LIMITED TIME USE
Contractor Date r- C) fff -r DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date l ~q L
'lea
NO. OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION
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
❑ 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). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency A�
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 OO
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 SU
and hereby authorize representatives of this County to enter
pon the above-mentione ro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignal�r�Yermittee �t Date