HomeMy Public PortalAbout4343TEMPLE CITY BLVD_Miscellaneous (2) WORKERS COMPENSATION DECLARATION 875 (2 90)
CE MISCELLANEOUS APPLICATION
' CE 875 '
1 h£rcby atf;mcert that I have a certificate of coment nc rest COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
Policy NoCompany FOR APPLICANT TO FILL-IN EUILGINa
❑ ADD*K.
Certified copy is hereby furnished UILDINGCI C13 3X Iv LOCALITY
Certified copy u fled with the county budding inspection
N¢wwe9r
department Lo wLITr ewoe.- er
Date Applicant ~ NEAREST /I D15TRICT Na agpur TrPe rw ea¢o BY
CLOGS.- ST XU(J (/ /S.y eoNnT t/
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL. o Y .Q
COMPENSATION INSURANCE 0ESCRIPTIBM Cor NO BLOCK HIGHWAY STATE MAJOR SVC
LOCAL d
_ _ .�ncul
(This sec[tOn need no[ be complet2d d the work Involved TRACT rNl ow oN or B aE¢ zONc SPECIAL CCNGITtONS O
by the permit Is for one hundred dollars (S160) or less) _ - DSE OF M�
at or Lor t
EXISTING BLDG '//
certify that in the performance of the work for which this OF
permit u issued 1 shall not employ any person in any manner W
ON¢ _ U
so as to become subject to the Workers Compensation La,,s AIL OCCUPANCY GROUPILIJ
1 wDoR /L/ y
Date Applicant Z
NOTICE TO APPLICANT If after making this Certificate of <;19O -4. U �0 7U ZJ� OCCUPANT LOAD
Exemption you should become subject to theeypAfal
1Vorkers
Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE
wrth comply with such provisions or this permit shall be T.AILER USE GEOLOGY INSPECTIONpec KnOWI E:1deemed revoked NO $
LICENSED CONTRACTORS DECLARATION occuPwner INSPECTION Pante Devices 1:1
I hereby affirm that I am hLensed under provisions of Chapter SAFETY PERMIT [LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi - El_
ness and Professions Code and my license Is In full force and - PARKING effect RED o P---,.ED
_ Prwc Ee
License Number Lie Class-
LIMITED TIME USE
Contractor Date Al.oowr.
❑ 1 am exempt from the l[Lenaing -equlrements as I em a rG
licensed architect or a registered professional engineer SIzE or n0 or I nP¢ TURE
acting In my professional capacity (Section 7051 Bus EXISTING BLDG STORIES
' mess and Professions Code) G tiZ FINAL APPROVAL
R¢S¢NT USE or BUILDING U As
Lie or Reg No Date
HOME OWNER BUILDER DECLARATION NO OP EXISTING BUILDINGS
ONO
Lor LONG USE IJI�Iyy I�I�ui /il/ r)1
I I hereby aff¢m that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Bmi 1 AM _::
ness and Professions Code) NO PARKING
❑ SPAC eS PROVIDED I
as owner of the property will do the work and the
structure is not intended or offered for sale (Section IIrrk�
7044 Business and Professions Code) 4010890 USE or BUILDING U /,
CONSTRUCTION LENDING AGENCY / m O P1
I hereby affirm that [here Is a construction lending agency G � ,LLL
for the performance of the work for which this permit is
Issued(Sec 3097 Civ C ) -f le
Lenders Name
•ROP09EO MAX OCC
Lender s Address PERMIT FEE 5�
I certify that I have read this application and state that the
above information u correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction TOTAL PEE -
and hereby authorive representatives of this County to enter r
upon the abov entione oDerty for inspectiU purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
71Z Y`*I
of Permitfee Date `