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• `WORF.ERS'COJiPENSAT70NDECLARATION
CE 875 111 84) MISCELLANEOUS APPLICATION {�
CE 878 fJ _
I hereby affirm that I have a certificate of consent to self - COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
unsure, or a certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN I ODRESe
Certified copy Is hereby furnished BYRONGsS 4343 Temple City Blvd. LOCAL,
Certified copy Is filed with the county budding inspection LOCALITY NEAREST -
department Temple Cit CA 91780 GROSS eT
Dale Apphcant NEAREST Valle Blvd Lower AZusa DISTRICT No our TYPE ¢ee¢D eY
CROSS ST coNaT
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL MA UO Nio Nd.�,.v
COMPENSATION INSURANCE DESCRIPTION LOT NO DLOCR ND• (CIRCLET - STATE MAJOR SECOND LOCAL
- ' - NO OF SLOGS
(Thus section need not be completed J the work involved TRACT NOW ON LOT ' USE zone SPECIAL CO numONS
by the permit is for one hundred dollars ($100) or tem) -- uen OF %Ueh Ouse �
aaxE OF Lor ¢xISTING G —
1'certify that m the performance of the work for which this
permit is issued, 1 .hntl not employ any person many manner OWN¢w A C Trade Center y
so as to become subject to the Workers' Compensation Laws M4IL OCCUPANCY GROUP _a a
d� 0
ADDRESS 4343 Temple Cit Blvd. w
Date Applicant TEL
NOTICE TO APPLICANT If, after making this Certificate of CITY Temple City No ( 818)350-8238 OCCUPANT LOAD
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Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensanon provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be "AMER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked Panic Devices
LICENSED CONTRACTORS DECLARATION occuPwner lNePEerioNf(]
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 0 (LOT ITEMS BELOW)
9 (Commencing with Section 7000) of Division 3 of the Busr nG OF EXITS
ness and Professions Code, and my license is in full force and CP
PL-J
effect s.IA.w IEcE* REO D ..,Duo
License Number Luc Class A _ �, LIMITED TIME USE
Contractor Date—
I
--`7�`"—�""
1 am exempt from the licensing requirements as I am a / �� �`� ROM .O INSPECTOR e
hmnsed architect or a registered professional engineer SIz¢OP ST of SI wruRE
acting m my professional capacity (Section 7051, Bus- ERISRIES
nwG SLOG 31 OOO Ft. NO OF
mess and Professions Code) _ FINAL APPROVAL
PRESENT USE of BUILDING Warehouse l
Lic or Reg No Date n
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HOME OWNER-BUILDER DECLARATION no OF ExISTING BUILDINGS V YI�
ON LOT AND USE 0 [ID[t[I-00111 11(1554
1 hereby affirm that I am exempt from the Contractor's �1J� " 77-x1) 1 AM11044
License law for the following reason (Section 7031 S, Busr
ness and Professions Code) NO PARKING 15
1, as owner of the property, will do the work and the SPACES PROVIDED
structure rt not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there ns a construction lending agency Whole ale and Warehose
for the performance of the work for which this permit Is ,
Issued(Sec 3091,Cry C)
Lender's Name
PROPOSED MAx Oee
Lender s Address
PERMIT FEE 25 00
I certify that I have read this application and state that the -
above information is correct I agree to comply with all County ussu wlicE Fee
ordinances and State 1 tvs relating to budding comtrucuon,
and authorize r presentatNet of this County to enter TOTAL Pee 25,00
up thea ve-mention d property t r Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature ermuttee Date