HomeMy Public PortalAbout9715 LAS TUNAS DR_Miscellaneous__ W�RKXRS'GOMPENSATION DECLAPATION -,;SM444 'MISCELLANEOUS-,
DSCE = gy2US• APPLICATI®N9E 875 (2-80)
I hereby affirm that I have a certificate-of consent to self I.
insure, or a certificate of Workers'Compensation Insurance,or COUNTY®F LOS ANGELES BUILDING�AND SAFETY DIVISION
�certifie thereof(Sec. ) f` - '
Policy N9 1 I FOR AP:PLICANT,TO•F.ILL IN BL�ILGING
' ADDRESS '
Certified copy is hereby furnishe UILDING r�
' 'D DRE SS LOCALITv
Certified 'copy is filed with t county:build' 'g inspe tion 1 7NEAREST
p LOCALITY CROSS ST.
Dat Applican NEAREST f DISTRICT NO. ROU, TY PROCESSED BY '
GROSS ST. t CONST.
C.E.RTIFICATE OF EXE PTIO ROM WORKER LEGAL '
DESCRIPTION LOT NO. BLOCK MAP �; NIGH WAY' STATE MAJOR SECOND LOCAL
COMPENSATION INS -RANCE No.:.. jCIRC
Le)` O_
NO.'OF' BLDGS. " USE ZONE SPECIAL CONDITIONS - V
'(THIS SBCtIOn neednot be=completed if.the work IRVOIVed TRACT NOW ON LOT
.by the permitis for one hundred dollars oress.
($100) l )
_ I USE of
SIZE OF LOT EXISTING BLDG. ,
I certify that in the performance of he work for hich 'this O
permit is issued, I shall not emplo y person in ny manner owNER U
so as to become subject.to the rkers' Com sation awS. • OCCUPANCY.G.ROUP,,
MAILLU
Dat Applicant CL
N.
NOTICE TO'APPI IGANT: er//kin;this'Certif fl .O.f .CITY NO
Lt� OCCUPANT LOAD
Exemption, you should become ject ,to the kers' l
Compensation provisions of the Labor Code, you must forth- APPLICATION,FOR EX'IT'.HARDWARE::
with comply with such provisions or this permit Shall be TRAILER,USE - GEOLOGY INSPECTIONQ .4� No Spec. Knowl: Els -
deemed revoked.'' . ❑
T• ,OCCUPANCY INSPECTION -'. ' Panic Devices
LICENSED,'.CONTRACTORS.DECLARATION
I hereby affirm that I am.licenidd under provisions of.Chapter' 1 SAFETY PERMIT (LIST ITEMS BELOW) j1
NO. OF EXITS �'.
9 (Commencing with Section 7000)of Division 3 of,the Busi-
ness and Professions Code, and my licenseJs-in full force and PARKING G.
effect. REQ'D PROVIDED .
IE _� r
SPACES - .
License Number' Lic.Class' 1'•
R� ' LIMITED TIME USE.
ContractorDate — v' TE DATE.
,'❑ .'.. _.• '• ' i ROMA .TO: ...
I am exempt'from the licensing requirements as I arh a ,,.
licensed architect or a registered professional engineer IZE OF NO.'OF: INSPE CTO R'8
acting in' my 'professioriai•.capacity (Section .705.1, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL-APPROVAL f
PRES9kT'USE OF•BU ILDING �.
Lic.•or Reg.No.' Date
HOME OWNER-BUILDER DECLARATION Wo.OF EXISTING HU)LU/NGs
•ON'LOT AND USE --
I hereby affirm that, I am 'exempt. from the Contractor's -r
License Law for the following reason (Section 7031.5, Busi-'
ness and Professions Code): 'NO.PARKING I a
.SPACES PROVIDED - s. •;��
I, as oner of the property, will do the work. and the
I' ;.
structure is not intended or offered foi sale (Section �° (` , 313.f i�ua_s j
7044.;Business and Professions Code) 1 •::
1PROPOSED USE OF BuIL'DIN •1' ,S'
CONSTRUCTION LENDING AGENCY i •1�F t
I hereby -affirm that there. is a construction•lending agency I' [ •
for the performance of,the work for which this permit is j T,1 X725 ,SIC).
issued(Sec. 30:97,.Civ:C.)•
.1 04.
C ;...! I itl _
Lender's Name y T.. I`''7 _:i I::v'+ " (.•:s-r,f 2 I�
PROPOSED pXt=•occ. ,.-, 1„•,,. .-.� •i t_{K 257
a Lf
Lender's Address_" 4 �. t3IJ ! Irl MIK 4•-II�iit
PERMIT FEE ray H-1
I certify that I have read.this application and state that the yry'
k N• t 1
abovein ation is.correct.I agree'to comply ISSUANCE FEE with all County � � d soI_;, �w5
ordina es and Stige laws relating to building construction, rF- y=_IK(" 2/221-39
and reby author' 'e representatives of this County to enter TOTAL FE'E,• nI % + L1- �,�
,up th6 above- entio property for inspection purposes. i' '•, s::-09
..SEE REVERSE FOR EXPLANATORY LAN-'U E I:z r, :V.z 1 #�I �u U7
�Jr a + 1'• P.fa
I
cr; CCJ
„
,q a f Permitte Date h,, r r t� "j ;,.-II ;
COUNTY OF LOS ANGELES
s *} DEPARTMENT OF PUBLIC WORKS
�I Int ► SAN GABRIEL VALLEY REGIONAL OFFICE
BUILDING AND SAFETY
THOMAS A.TIDEMANSON.Dlreetor 125 S. Baldwin Avenue
Arcadia, CA 91007
(818) 574-0941
MICROFILM INFORMATION
Record Search
1933-1954
Building Address: �� � �Q` Locality
Pres Address
Tract. No. Lot No. Lot Size
- " Bui]:dzng--Perm t-- —Issue Date -Final Date '-
Descriptio of Work
Sq. Ft. .
ilding Pe it # Issue ate Final Date
e ription f Work .
11 S . Ft
7 B ilding P m t Is ue Dat 'n 1 Date
D scription of
Sq. Ft.
•,B ilding Permit # Issue Date Final Date
_De;cri-pti.on_of Wor
- -
q.
r
Bu' ding Permit Issu a Fina -
Description of Work
Sq. Ft.
Sewer Permit # Date Issued
Private Disposal System Date Inspected
Public Sewer Connection
Date '�By: . Ac