HomeMy Public PortalAbout9575 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
I 4affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insurere,, o or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab.C).
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
FlCertified copy is hereby furnishedUILDING^575 Las Tunas
ADDRESS 575 LQCALITY
0 Certified copy is filed with the county building inspection OCALITY Temple City � Ca. 91780 CROSS ST
NEAREST
department
Date /
Applicant AREST Las Tunas / Tem 1e C1t BZ �•3� T NO G TYPEONST PRO ESSED BY
CROSS ST. „ C �'^
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIG HW AV
rv0 /�� (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL 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
permit is issued, I shall not employ any person in any manner .NERD f Qt $ V. v
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP
Date Applicant ^7�
424 N. Lake Pasadena 91101
ADDRESS V
TEL OCCUPANT LOAD LLI
NOTICE TO APPLICANT• If, after making this Certificate of CITY Pasadena ND. 681-2365 0_
Exemption, you should become subject to the Workers' 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 [3 ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING REQ D D PROVIDED D
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a PROM' TO.
licensed architect or a registered professional engineer SIZE OF No OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- E ISTING BLDG. STORIES S NATURE
mess and Professions Code) FINAL APPROVAL /0
PRESENT USE ITI OF BUILDING Et G
Lic.or Reg No. Date
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, Busi-
ness and Professions Code). NO PARKING
F11,
PROVIDED I, as owner of the property, will do the work and the ;9 5 94.8 A
structure is not intended or offered for sale (Section
7044,Business and Professions Code). rl� # o 0 o 0 8 8
CONSTRUCTION LENDING AGENCY ROPOSED USE OF BUILDING V►J"
0 0 0 0 0 0 0
I hereby affirm that there is a construction lending agency Retail Beauty Supply
for the performance of the work for wluch this permit is 1 1.,17-86
issued(Sec 3097,Civ.C.). \�
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and ereby authore representatives of this County to enter TOTAL FEE
u n the above- nned property for Inspection purposes.
• SEE REVERSE FOR EXPLANATORY LANGUAGE
eolc_ 1986
Signature of Permittee Date