HomeMy Public PortalAbout9247 LAS TUNAS DR_Miscellaneous__ WORK,RS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
CE 875(11-84)
I hereby
affil
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. CompanyFOR APPLICANT TO FILL IN BUILDING +")4 C""�'.
ADDRESS Q( �,J
Certified copy is hereby furnished. Bu'LDING LOCALITY
% R. LAS TITNAS DR-
DRESS9247
FCertified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT N OUP TYPE P CESSED BY
CROSS ST. LAS TUNAS DR. & ALASANDRO �' CONST•-'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
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 OWNER JAMES CHENG S.:)
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP Q=
IL
ADDRESS 9247 E. LAS TUNAS DR. o
Date Applicant c3
NOTICE TO APPLICANT: If, after making this Certificate of c'rY TEMPLE CITY No $1$ 309-1210 OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
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.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM' ❑ (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 ,r�� C
/vOS-5 PARKING
effect. SPACES REQ'D D PROVIDED D
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
F1 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional en E
neer SIZE OF NO. OF NSPECTO
acting in my professional capacity (Section 7051,, Bus- '' II EXISTING BLDG. STORIES 1 NATU E
iness and Professions Code). J FINAL APPROVAL
(A', PRESENT USE OF BUILDING
Lic.or Reg.No. Date .
I
I
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE ��/26 33sF
I hereby affirm that I am exempt from the Contractor's 1111�"�Q��
License Law for the following reason (Section 7031.5, Busi- 1-I 1� 1 Pmx„31;
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING y
I Hereby affirm that there is a construction lending agency FOR OFFICE USE ONLY
for the performance of the work for which this permit is 1
issued(Sec. 3097,Civ.C.). )U\
Lender's Name
PROPOSED MAX. OCC. �� •�t"
Lender's Address K p 0
PERMIT FEE c/
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 representatives of this County to enter TOTAL, FEE Oa
on the above-mentioned property for inspection purposes.
4 SEE REVERSE FOR EXPLANATORY LANGUAGE
1/� >s
Signature of Permittee Dat