HomeMy Public PortalAbout4333TEMPLE CITY BLVD_Miscellaneous (2) WORKERS COMPENSATION DFCLARATION CE 875 MISCELLANEOUS APPLICATION {j
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msur�'b"of fePtlficatthate of Workers eCompensation cate of insurances o� COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certifie4cgpy'herenf(See 3300 Lab C )
Policy No ' Compan> FOR APPLICANT TO FILL IN Buii.o lNo
ADORE..
❑ Certified copy Is hereby furnished "DDae.s -' I LOCALITY r
Certified copj E filed with the county budding Inspection NEAREST
department LOCALITY fill, CROs. Sr
Date Applicant NEAREST DISTRICT NO oRgLIP TYPO PR SED er
t eRO.s
By K e1 eoN
CERTH ICATL OF EXLMPTION FROM WORKERS 'LEGAL t QJO� '
DEsc RIPT ON LOT No eLocx IONrwr Y
COMPENSATION INSURANCE �wr_ STwre MAJOR BE o LOCAL 1
(ciwcLC1--c =d-
-(ThiS section need not be completed if[he —work-in—volved rawcT J Nor oN Lor use zone SrecuL cowoanors -
by the permit is for one hundred dollars (S 100) or less) usE oP
SIZE OF Lor ¢xi.Twa BLDGcr
I certify that in the performance of the work for which this NER
O
permit is Issued I shall not employ any person In any manner U
so as to become subject to the Workers Compensation laws MAIL OCCUPANCY GROUP W
ADDRESS r3 1Jn - ��0 d
Date Applicant N
NOTICE TO APPLICANT If after making this Certificate of cl� �. NoRLRS1�j-��� OCCUPANT LOAD
Exemption you should become subject to the Workers
Compensation provaions of the Labor Code you must forth A LICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER us¢ GEOLOGY INSPECTION
deemed revoked No Spec Knowl El
LICFNSLD CONTRACTORS DECLARATION occurwwcr INSPECTION Panic Devices ❑
I hereby affirm that 1 am licensed under provisions of Chapter SAPETY PERMIT El (LIST ITEMS BELOW) No oP EXITS
9 (commencing with Section 7000) of Division 3 of the Busi p `�
ness and Professions Code and my license Is in full force and �rd "X 'U // / Pw ExINo
effect (('' /" I ' �,/ PAIn IN RED D PROv....
License Namber Lie Classaa— I !1-s (.L yf`- re�Q (1/dS
ES
LIMITED TIME USE
Contractor. Date AT. DAT•
1am exempt from the ItLensing requirements as I am a
ECTOR 9
,tensed architect or a registered professional engineer vi.E OF No of INV NwruR¢
acting in my professional eapaciq (Section 7051 Bus- EXISTING BLDG 1 'S _ STORIES
mess and Professions Code) FINAL APPROVAL
PRESENT USE OF BUILDING
Lie o- Reg No DatL
HOME OWNLR BUH DFR DECLARATION NO OF EXISTING BUILDINGS # • • - • 3 7
ON LOT AND use
I hereby affirm that I am exempt from the ConlmLtors 1 ' 96Q50
License Law for the following reason (Section 7031 5 Busi - 6 Q 5 0 ZTS
nes%and Professions Code) No PAR.IN. 'A . .
Srwc"PROVIDED
❑ I as owner of thL property will do the work and the 03,12-87
structure is not Intended or offered for sale (Section
7044 Business and Professions Code)
P ROrOBBO USE Or BUILDING
CONSTRUCTION LLNDING AGLNCY �� L
1 hereby affirm that them Is a conslruLtlon lending agency
for the perform.mcL of the work for which this permit is
issued (Sec 3097 Gs C )
Lender s Name
S P N
Lender 5 Address PERMIT PEE
I certifj that 1 hale read this application and state that tin,
abose informatl I Is L rcct 1 agree 1.LOmply with all County ISSUANCE
ordinances a I Is relating io budding construction TOTAL FEE
4n4hereby ut onie re resentatives of (his County to enter rS
pO the Ie enII0 ed propLrty for Inspection pure)ses SLF RLVLRSL FOR EXPLANATORY LANGUAGE
L—qfFiture oY Permittee D to