HomeMy Public PortalAbout9523, 9525 LAS TUNAS DR_Miscellaneous__ i WORKERS'CObIFENSATION DECLARATION CE 875 i11-84)a MISCELLANEOUS APPLICATION Z7
CE 87
I . I hereby affirm that i have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
t insure, or a certificate of Workers'Compensation Insurance. or
a certified copy thereof(Sec. 3800,Lab.CA.
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING
ADDRESS 'J02,y L457i"7aJ��
Certified copy is tiled with the county building inspection LOCALITYNEAREST
department. Temple City CROSS ST.
Date Applicant NEAREST DISTRICT NO: GRO,}}}JJJP JTY,E PRO SSED BY
CROSS ST. re L�` /� CONST
1
CERTIFICATE OF EXE.IPTION FROM WORIEERS' I LEGAL O�'7 (J //f
COMPENSATION INSURANCE I DESCRIPTION LOT NO. ;BLOCK i M�1N HIGHWAY STATE MAJOR SECOND LOCAL
s INC- OF BLDGS. - (CIRCLE)
(This section need not be completed if the work involved 1TRACT NOW ON LOT ru-7-E ZONEISPECIAL CONDITIONS
by the permit is for one hundred dollars (SIOO) or less.) ;
f USE TINGOF
)51�= OF LOT I EXISTIBLDG.
I certify that in the performance of the work for which this
permit is issued. I shall not employ any person in any manner DwNER r (�
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
MAIL
I a aDDREss
74'dY JeU ur��S
j Date Applicant
T P FCertificate
TEL. OCCUPANT LOAD
NOTICE O APPLICANT: I., after.makinE this Certi icate of cr,Y No. -
Exemption. you should become subject to the
Compensation provisions of the Labor Code, you must forth APPLICATION FOR 3 XIT HARDWARE:
t1, with comply with such`provisions or this permit shai be -Ra1L R USE GEOLOGY IN SPE'CTICN N
deemed revoked. o Spec. Knowl,
LICENSED CONTRACTORS DECLARATION 3 OCCUPANCY INSPECTICN$$ Panic Devices
I hereby affirm that I am licensed under provisions of Chanter SAFETY PERMIT � (LIST ITEMS BELOW)
1 9 (commencing with Section 7000) of Division 3 of the Susi- No. of EXITS
j ness and Professions Code, and my license is in full force and `7 /y � (�
eIteet. / S�� "ACES
RKING REO'O I PROVIDED ! I
{ S
P
1 License Number Lie. Class LIMITED TIME USE
N Contractor Date DATE DATE
w
I am exempt from the licensing requirements as I am a FaJM: -D'
} licensed architect or a registered prof?ssional engineer s,Z of No, OF IN SPE CTO RAS
z
I 0 EXISTING BLDG. - STORIES SIGN URE acting in my professicra. capacit} ;Sectio, 7J5 i, Bus-
(ness and Professions Code;. �� zZ
SJ }PRESENT USE CF BUILDING Fl-NAL APPROVAL
Lie.or Reg.No. Date
E 1 � `
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �X 1U
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's j
j i License Law for the following reason (Section 7031.5. Busi-
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). p
A PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
{ for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). r
Lender's Name
PROPOSED MAX. OCG.
Lender's Address 1.:D
} PERMIT FEE 25.00
I certify that I have read this application and state that the 1
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 I TOT AL, FEE 25.00
I i upon the v -ment'oned property for inspection purposes. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE J.
Signature of Permittee Date "t
I`sx
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