HomeMy Public PortalAbout4509TEMPLE CITY BLVD_Miscellaneous ATION
WORKEh that IP have
a, ONDECLAf conwn CE 875 M ISCELLANEOUS APPLICATION {�
CE 876 I1 t 84) LJ
I hee, o a cert that I have a�s'Co en of consent to self 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) 1
Policy No Company FOR APPLICANT TO FI LL IN BUI OOK R
RBBe
Certified copy is hereby furnished euILD—
wDnweee z7o xpiQe,c4rY oLvo 20l & �&oZo
department Copy Filed with the county budding inspection LocwLlrYPLF �� �� 9/70r/ NEAREST
C.
ST
Date Applicant NEARESTn ur T • c¢ea¢D ev
CROSS ST LpWM /4Z a.4 /Z/� DIerRlar T _o0 coNYPEBT
CERTIFICATE OF EXEMPTION FROM WORKERS; LEGAL
COMPENSATION INSURANCE OSSCR IrTtON LOT NO BLOCK .....Al STATE MAJOR SECOND LOCAL
xo (ClwcLw)
NO OP RLO68
(This Section perm peed not be completed If the Work or less TRACT No
ON LOT USE ZONE O•C CIAL CONDITIONS
by the permit Is for one hundred dollars ($100) or less) USE or ry
Or LOT v
1 certify that in the performance of the w 8120 6%ISELOO
work for which this o
permit is issued, I shall not employ any person many manner O.New �p '(.0
A
so as to become subject to the Workers' Compensation Laws MAIQQTCrr�NC� OCCUPANCY GROUP
Date Apphcant
wD ow Cee d'5
0
c W
NOTICE TO APPLICANT If, after making this Certificate of CITY ra �rPeC/ p4noL���.f�3�yy� OCCUPANT LOAD o_
Exemption, you should become subject to the Workers z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER US¢ ❑ GEOLOGY INSPECTION ❑ No Spec Knowl ❑
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter awr ETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000)'of Division 3 of the Busr NO Or EXITS
ness and Professions Code,and my license is in full force and ��� 6 .�/A/ �.�L/..r '�
effect PARKING 1�
�w� s.s � SPA Cee REG o �J PROvIOBn
License Number Lie Class Alee4 ,/r&C' r
Contractor Date � lewaeerG 61G�//> 'fZop)� PAr�IMITED TIME USE DAYS
TOy�r��
El 1 am exempt from the licensing requirements as I am a / --rG 17sv
licensed architect or a registered profesmonal engineer EXN
INSPecoR
acting in my professional capacity (Section 7051, Bus EXISTING BLDG srowl9S Slawwuw s
mess and Professions Code) FINAL APPROVAL '`
Lie or Reg No Date PRESENT UeE Or BUILDING (f
L
Ftp �1JILD NS NO FE
HOME OWNER-BUILDER DECLARATION NG O EXISTING UaK au uowas,
ON LOT AND U8B aP��
I hereby affffm that I am exempt from the Contractor's _ [•�fOl/) -
nessLicense
an Law for the following reason (Section 7031 5, Busr I� ��001 *�2u/r7,`
ness and Professions Cade) NO PARKING _
El1, as owner of the property, will do the work and the SPACES PROVIDED 9271 1 AM10:30
structure is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED UES or BUILDING _
1 hereby affirm that there is a construction lending agency O /C6r- .+M/ / 1F /,C,/�
for the performance of the work for wluch this permit Is
issued(Sec 3097,Cry C)
Lender s Name
PROPOSED MAX OCC
Lender's Address _
I certify that 1 have read this application and state that the PfiRMIT Ffifi VUi
above Information is COlrect I agree t0 COm hall County Issues NCE FEC -
orduiances and State laws rely twig to b ons[ruc[wn, o
and PW
is ounty to enterTOTAL FEEPOcoon purposes-/1` _ SEE REVERSE FO EXPLANATORY LANGUAGE
7' Date