HomeMy Public PortalAbout9553 LAS TUNAS DR_Miscellaneous__ +" r WORKERS' COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
20-0063DPW12/90
I hereby affirm that I have-a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '
insure,or a certificate of,Wdikers'Compensation Insurance, or ll
a certified copy thereof (Sec. 3800, Lab.C.)
Policy'No, Company FOR APPLICANT TO FILL.IN BUILDING
-' BUILDING ADDRESS ADDRESS
❑ Certified copy.is hereby;furnished. X 9553 Las Tunas, Temple City.CA LOCALITY
❑ Certified copy is filed with the county building inspection CITY ZIP
i department. Tem le Cit NEAREST
R ss sr.
' Date ' - - Applicant - SIZE OF LOT NO.OF BLD 5.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' CONST.
- COMPENSATION INSURANCE TRACT BLOCK LOT NO. 0
. MAP - HIGHWAY V
NO. ICIRCLEI STATE MAJOR SECOND LOCAL..
(This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 0
( I certify that in the performance.of the work for which this T f r Lyo. Q
permit is issued.I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. AD RES a-
V� OCCUPANCY GROUP Cn
Z
{ Date Applicant CIT / G ZIP
NOTICE TO APPLICANT: If. after making this Certificate s 9161Z4( OCCUPANT LOAD
of Exemption. you should become subject to the Workers' APPLICATION FOR
Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE:
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
( revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION CX Panic Devices ❑
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 Business NO.OF EXITS
and Professions Code. and my license is in full force and effect. ame O uslness
License Number Lic. Class PARKING• REO'D PROVIDED
Digitol Kodak Professional Pro-center SPACES ��JJ
t I Contractor Date _ LIMITED TIME USE
Elm I aexempt from the licensing requirements as I am a FROM: DATE TO. DATE
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Business SIZE OF NO.OF INSPECTOR'S
{\ I
and Professions Code). EXISTING BLDG. STORIES SIGNATURE.
_
Lic. or Reg.No. - Date PRESENT USE OF BUILDING FINAL APPROVAL Z
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE -
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code): NO.PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING
Business and Professions Code).
REtail Whoesale Picture Framing,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for Picture Album, Digitol "Proeenter
the performance of the work for which this permit is issued
( , (Sec. 3097, Civ.C.). PROPOSED MAX.OCC.
' Lender's Name APPU ANC T(PRINT)Yin ftN0309-0139
Lender's Address ADDRESS nru
{ I certify that I have read this application and state that the 6316 N Muscatel Ave San Gabriel CA 91 75
above information is correct. I agree to comply with aIi County PERMIT FEE
ordinances and State laws relating to building construction,and -
hereby authorize representatives of this County to enter upon ISSUANCE FEE -the above-menti ro erty for inspection purposes.
TOTAL FEE
3— t1 •2 SEE REVERSE FOR EXPLANATORY LANGUAGE
f Signature of Permittee Date