HomeMy Public PortalAbout4509TEMPLE CITY BLVD_Miscellaneous (2) WORKERSth;t I hve'a Cert DECLARATION CE 875 MISCELLANEOUS APPLICATION �1
CE 875 (11 84) LJ
I hereby a arm that I Workers'
s'Co Certificate of consent to sell COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certifjpte of Workers'Compensation Insurance,or
a certtfic8 copy thereof(Sec 3800, Lab C)
Policy No Company FOR APPLICANT TO FI LL IN Bull.OINa S�
ADDRESS
Certified copy is hereby furnished X BUILDING ra r6NA-4F G� &.. 202.
wooREaa Locwur
❑ Certified Copy u Ciled with the county budding inspection �MPGE �� 9i�Fo NEAREST
LOCA LITY
department cnoee ar
Date Applicant NEAREST DISTRICT NO o our TYPH R ¢[n¢D BY
CROSS Sr 0 /rZW� 80,10 `O� co NS
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL �•/
COMPENSATION INSURANCE DUSCRIPTION I LOT No BLOCK MAP IOL..
No jC,"Cuj STATE MAJOR SECOND LOCAL
(Thu section need not be completed if,the work involved TRACT No of .Loa[
Now on Lor tie¢ zon[ SP[CIwL CONDITIONS
by the permit is for one hundred dollus'($100) or less)
or
�a
I Certify that m the performance of the work Cor aIi[ OF LOT EXISTING
Rauch this w� ExiSTITInG BLOC K
permit is issued, I shall not employ any person many mannerX /7t-
ab as to become subject to the Workers' Compensation laws x' OCCUPANCY GROUP o
ADDRESS ` o S/
Date Applican
W
{ U
NOTICE TO APPLICANT If, after making this Certificate of CITY jEMotEc� 917Irra F/d'0'3-VY3 OCCUPANT LOAD a
Exemption, you should become subject to, the Workers
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLoar IrvaPEcnoN ❑ No Spec KrIOWI
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust NO PERMIT ❑ (uar IrEMe BELOW) NO of EXITS
nen and Professions Code,-and my license is in full force and��JJ 7
effect X w2� PARKINe
SPACES Rao0 PRGvto[D
License Number Lie Class A,0,VCML SJfC-MS
Contractor Date TEHPbtc C/ BL 90202 aATLIMITED TIME USE .AYR
0 1 am exempt from the licensing requirements as I am a MMPLE G 1 ZPQ "D"
TO
Licensed architect or a registered professional engineer SIz[OF no of INSPECTOR 9
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG $TONI 91 NATURE
mess and Professions Code) FINAL APPROVAL `
Lie or Reg No Date PR[S[nr tie¢ of [u uDlNa
Ro sS16^0C_ iCFfj/�7C O
HOME OWNER-BUILDER DECLARATION 4 NO OF EXISTING BUILDINGS w
ON Lor AND uae y
I hereby affirm that I am exempt from the Contractor's A
License Law for the following reason (Section 7031 5, Bust I �v I 0000-M- 4/20/93
ness and Professions Code) NO PARKING
1, as owner of the property, will do the work and the SPACES PROVIDED 9270 1 AM10:30
structure is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSKO USE of BUILDING
I hereby affirm that there u a construction lending agency 0 SCE
for the performance of the work for which this permit u
issued(Sec 3097,Civ C) (,'p/yJ vj�f-L pRoFi9m�in/
Lender's Name
PROPOSED MAX Bee
Lender's Address
PBRMIT FEE I certify that 1 have read this application and t that the
above information is correct I agree to comp with County ISSUANCE FEE-
ordinances and tate Taws reWbuWretraction,
and herebyriz rey to enter TOTAL FEE
upon the -men ed ourposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
41141; A
Signature of Permittee Date