HomeMy Public PortalAbout9868 LAS TUNAS DR_Miscellaneous__ I WORKERS'COMPENSATION DECLARATION '75M444 —,
ICE 875 (11-84) MISCELLANEOUS APPLICATION
1 hereby.affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES •13UILDING AND SAFETY DIVISION
`insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C).
Polis No T R A. Company eAlRJJW09 CL'NPeI� Cn. BUILDING p!p
FOR APPLICANT TO FILL IN O{JO
ADDRESS
Certified copy is hereby furl shed BUILDING x^C ,
B ADDRESS 8 L% TtiN�S LOCALITY < /
I 0 Certified copy is filed with th county bu ding m eC on LOCALITY NEAREST
Temple City
Dateddepartment. cRoss sr
"Applicant NEAREST []STRICT NO G P TYPE CESSED BY
CROSS ST nes St. CON
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor NO. 43$ BLocK MAP HIGHWAY
NO OF BLDGS.
Nn (CIRCLE) STATE MAJOR SECOND LOCAL
I
i (This section need not be completed if the work involved TRACT G/56 NOW ON LOT ' USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 141�� EXISTING BLDG USE OF
I certify that in the performance of the work for which this SIZE OF LOT
permit is issued,' I shall not employ any person in any manner OWNER E� /�J (y d i
so as to become subject to the Wc-rkers' Compensation. Laws.
K 1/ 7�(/ I}� `t OCCUPANCY GROUP
CJ -,�---
'• f ~~- `ti t.--.--
L X MAIL ADDR ESSIU✓1 _ U V
Date_J? _ Applicant_" _ _� _
NOTICE TO APPLICANT: If, aftet-making-thisiCertitic to of CITY�j TNO. OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth
1 with comply with such provisions or this permit shall be
deemed revoked TRAILER USE ❑ GEOLOGY INSPECTION ❑ NO Spec. Knows.
Panic Devices
LICENSED 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 Busi- NO OF EXITS
ness and Professions Code, and my license is in full force and FF
effect PARKING SPACES RE
Q'D D PROVIDED O
License Number Lie Class LIMITED TIME USE
Contractor Date DATE DATE
El FR>M TO
I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer slzE OF NO OF INSPECTOR'S
acting m my professional Capacity (Section 7051, Bus- 1'EXISTING BLDG STORIES IGNATURE
iness and Professions Code) F I C W A L APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg No. Date
' HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS �A
ON LOT AND USE - //`� NO-I FEE ?' 4/ _
1 hereby affirm that I am exempt from the Contractor's i 2,393
ty j License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code). No PARKING
1, as owner of the property, will do
PROVIDED do the work and the I
structure is not intended or offered for sale (Section
�) 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY X I PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency
`I 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
1 certify that 1 have read this application and state that the i PERMIT FEE 25.00
above information is correct. I agree to comply with all County I ISSUANCE FEE
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL. FEE 25.00
upon the above-mentioned property for inspection purposes.
SLE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date