The URL can be used to link to this page

Home My Public Portal About9568 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(2-801 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or � � a certified copy thereof(Sec. 3800,Lab.C.) Policy No Company FOR APPLICANT TO FILL IN ADDRESS oe ❑ Certified copy Is hereby furnished BUILDING LOCALITY ADDRESS 9568 E Las Tunas Dr. _ ❑ Certified copy is filed with the county building Inspection NEAREST department LOCALITY Temple City 91780 CROSS ST Date Applicant EA REST T DISTRICT NO. �_UP TYPE ROCESSED BLO CROSS ST. lem le CitCONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL } (This section need not be com leted if the work involved NO -OF BLOGS. USE ZONE: SPECIAL CONDITIONS (L P TRACT NOW ON LOT O by the permit is for one hundred dollars ($100) or less.) USE OF U SIZE OF LOT EXISTING BLDG. 'I certify that in the performance of the work for which this permit Is issued, I shall not employ any person In any manner WNER Gregory & Carol;ne Mode'sti O so as to become subject to the Workers' Compensation Laws AILOCCUPANCY GROUP DDR 25286 Ave Ramada w' Date Applicant a' TEL. NOTICE TO APPLICANT• If, after making this Certificate of CITY' Homeland No. OCCUPANT LOAD Z_ Exemption, you should become subject to the Workers' Ca. 9234$ - APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit Shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. C] ❑ No Spec. KnoWl..0 LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION . Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT V (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license Is In full force and PARKING. esf'fect. SPACES REQ'D PROVIDED License Number LIc Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM- TO licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXIS NG BLDG STORIES SIGNATURE iness and Professions Code). RESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date ` NO O EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION ON LOT AND USE - I hereby affirm that I am exempt from the Contractor's License Law'for the following reason (Section 7031.5, Busi- ness and Professions Code) NO. PARKING SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the ;?,2,2,61 A structure is not intended or offered for sale (Section ,• • • • 8 8 7044, Business and Professions Code) t• I 1 ROPOSED USE OF BUILDING Cocktail Bar .;• • • •'• • 2 CONSTRUCTION LENDING AGENCY Oi�}2rbi—8 4 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). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE 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, TOTAL FEE and y authorize represen s of this County to enter abov mention p for inspec on purposes SREVERSE FOR EXPLANATORY LANGUAGE n ure o ermittee Date I WORKERS'COMPENSATION DECLARATION 20-003DPW12is0 MISCELLANEOUS APPLICATION �- 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 Wdrkers'Compensation Insurance, or i a certified copy thereof (Se?_ 3800, Lab.C.)• - Policy No. Company FOR APPLICANT TO FILL IN BUILDING BUILD G ADDRESS ADDRESS Certified copy,ishereby,furnished. SVS Certified copy is filed with the county building inspection CI NEARET department. -7 q p Cl ziP / NEAREST . 1 ! L Date Applicant i SIZE OF LOT NO.OF BLOGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS' I CONST. I ' COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP HIGHWAY O (This section need not be completed if the work involved ^ro (CIRCLE) STATE MAJOR SECOND LOCAL P ASSESSOR MAP BOOK PAGECC by the permit is for one hundred dollars ($100) or less.) PARCEL USE ZONE SPECIAL CONDITIONS I certify that in the performance.of the work for which this ^arty er - EL i permit is issued. I shall not employ any person In any manner so as to become subject to the Workers' Compensation Laws. ADDR s _ OCCUPANCY GROUP TY *� Date Applicant CI _ ZIP L✓� Z NOTICE TO APPLICANT: If, after making this Certificate 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 OC this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ ( ' No Spec.Knowl. ❑ revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ ` I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) I 9(commencing with Section 7000)of Division 3 of the Business Name o US ess NO OF EXITS and Professions Code,and my license is in full force and effect. ' PARKING• REQ'D License Number Lic PROVIDED Class SPACES llJ Contractor - Date LIMITED TIME USE -. - IEl DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: hcensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES GNATURE. Lic or Reg. No - Date PRESENT USE OF BUILDING FINAL APPROVAL Z4/ 03 HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS I 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 7044,1 PROPOSED USE OF BUILDING L L Business and Professions Code). 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.). PROPOSED MAX OCG i Lender's Name APPLICANT(PR)M) EL o Lender's AddressAp�s y I certify that I have read this application and state that the C L above information is correct. I agree to comply with all County PERMIT FEE I ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE i 4 the above-mentioned property for inspection purposes. I TOTAL FEE % SEE REVERSE FOR EXPLANATORY LANGUAGE Ignat a of Pe ittee Date