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HomeMy Public PortalAbout9659 LAS TUNAS DR_Miscellaneous__ WORfCRS'COMPENSATION DECLARATION CE 8454(2 80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self insure, ori a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ico Certified copy is hereby furnished. BUILDING LOCALITY CJ ADDRESS 9659 Las Tunas � Certified copy is filed with the county building inspection NEAREST 7il department. LocALITr empCROSS ST. le it Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROC SSED T3Y CROSS Sr. Kauffman FA CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. 3S .. MAP IGMWAT CIE) STATE MAJOR SECOND LOCAL CL (This section need not be completed if the work. involved r NO. OF LOT USE ZONE SPECIAL CONDITIONS O P TRACT -J NOW ON LOT by the permit is for one hundred dollars ($100) or less.) , U USE OF SIZE OF LOT EXISTING BLDG. 1= I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER Estate of Gwendulyn E. Harris n O so as to become subject to the Workers' Compensation Laws. MAIL ttristy OCCUPANCY GROUP ADDRESS9659 Las Tunas W Date Applicant CL TEL_ t" NOTICE TO APPLICANT: If, after making this Certificate of CITY Temple City NO. 286 7634 OCCUPANT LOAD Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. ❑ ❑ 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) NO. OF EXITS a 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. PARKING. SPACES REO'D D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ —0— TO: I am exempt from the licensing requirements as I am a. licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 2 SIGNATURE iness and Professions Code). PRESENT USE OF BUILDINGFINAL APPROVAL Retail knit shop 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 1 2 B A License Law for the following reason (Section 7031.5, Busi- ness 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 • • • • • • • z 7044, Business and Professions Code). PROPOSED USE OF BUILDING Retail knit shop - 09,22-81 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.). 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 S laws relating to building construction, TOTAL FEE and hereby aut ze representatives of this County to enter upon th o e- entioned pr erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i SignatyTe of Permittee Date I WORKERS'COMPENSATION DECLARATION 175M444 -MISCELLANEOUS APPLICATION CE 875 (11-84) I hereby affirm that I have a certificate of consent to self insure, or a certifihte of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certifie&copy thereof(Sec.3800,Lab.Q. .: r Policy No. Colilpany FOR APPLICANT TO FILL IN BADDRESUILDING � S Certified copy is hereby furnished. E ) /�/ LOCALITY �Ffi ADDRESS CJ - �—✓1/ Certified copy is filed with the county building inspection OCALITY O cRoss st. department. L�, Cit T Date Applicant NEARESTDISTRICT NO. G UP TYPE CESSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (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. a I certify that in the performance of the work for which this I o permit is issued, I shall not employ any person in any manner OWNER AO ADDRESS Z '! _--'> so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP � Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of CITY (_ �' TEL OCCUPANT LOAD 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 USE ❑ GEOLOGY INSPECTION E] No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El I hereby affirm that I am licensed under provisions of Chapter 1 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEMS BELOW) i NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING R6Q'D DPROVIDED SPACES LL��JJ License Number Lic. Class EL i G� LIMITED TIME USE Contractor Date I DATE J �p ���^ �_ ElI am exempt from the licensing requirements as I am a PROMI TOI licensed architect or a registered profbssional engineer SIZE OF NO. OF INSPECTOR'S EXISTING BLDG. STORIES SIGN RE acting in my professional capacity (Section 7051, Bus -L• -rte iness and Professions Code). tom' -'- '- r FINAL APPROVAL PRESENT USE OF BUIL , ,-. DING �Ilti i• .}I Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXIS ING BU LDINGS Gt 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 l-„pnrf ness and Professions Code): No. PARKING "pp, I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section �(,�G , 16 &0—1 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency /d-L L 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 1 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 up above- tinned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I Signature of Permittee Date