HomeMy Public PortalAbout6003 RENO AVE_Miscellaneous__ } JS'COMPENSATION DECLARATION CE 875(1 1-84) MISCELLANEOUS 'A'P L I C AT I O N
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mj..,1�afcert that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
ate, ori a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q. -
PolicyNo.t Company FOR APP LI CANT TO FILL IN BUILDING moi`/�n r� r V�
ADDRESS CC1l. lJ �..J
Certified copy is hereby furnished. BUILDING
ADDRESS 6003 Reno Avenue LOCALITY
Certified copy is filed with the county building inspection LOCALITY
department. Temple Cit CA 91780 OR%• .&"",?[f, C i
Date Applicant NEAREST DISTRICT NO, GROU TYPE r PRO $ED BY
CROSS ST. F CONST. /
or
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL • -
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK- NOP RCLEI STATE MA'-310"A.E CON CAL
NO. OF BLDGS.
50
(This section need not be completed if the work involved TRACT 9904 NOW ON LOT 2 USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF O 1Ce i{
SIZE OF LOT 50X158 EXISTING BLDG.
I certify that in the performance of the work for which this C7
permit is issued,I shall not employ any person in any manner OWNER Robert & Joanjia EldridRp y
so as to become subject to the Workers' Compensation Laws. MAIL :OCCUPANCY GROUP o
Date Applicant ADDRESS 6003 Reno Ave. p w
NOTICE TO APPLICANT: If,after mak' this Certificate of CITY TEL. 018 309-9636 OCCUPANT LOAD
mg Temple City NO, z
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: _
Compensation provisio4s of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ '
deemed revoked. ❑ ❑ No Spec. Knowl.
'LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION i] 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. PARKINGSPACES REq.D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
F] 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 SI URE
iness and Professions Code). S ca FINAL APPROVAL
Lic.or Reg.No. Date
PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE 2 - house and
I hereby affirm that I am exempt from the Contractor's arage
License Law for the following reason (Section 7031.5, Busi g — - -•-
ness and Professions Code): . PARKING -• - L`''=1�
I, as owner of the property, will do the work and the SPACES PROVIDED 3
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structure is not intended or offered for sale (Section _ S.
_.I ..
7044,Business and Professions Code). I__ -�;:;r
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING arae and office
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.Q.
Lender's Name
PROPOSED MAX. OCC. I 4i•, •,' „__ ,,, ,_. .._.. .. .
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 f� -
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
�titioned-g erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat re of Peitui�t Date