HomeMy Public PortalAbout4516TEMPLE CITY BLVD_Miscellaneous WORKVRS'COMPENSATION DECLARATION CE 876 MISCELLANEOUS APPLICATION
i he by affirm that 1 have a certificate of consent to sell
ulwrd, or a certificate of Workers nw
Comperatn Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a Certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN
BUILDING —16
Certified copy is hereby furnished nulLOn.
RQaBL LOCALITYADD
i
13 Certified copy is filed with the county building inspection
department -t—
LOCALITY NQ wR¢tT
CRO88 9T �,
Date Applicant N¢wwQaT 1 OISTRIC�.fljjj111 O uP TYPE FROCK ED BY
CR019 �.' 1}�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL va
Pc
COMPENSATION INSURANCE DQa C RIPTrory Lor No cLocK A. 1...A
NO (CI CLII STATE MAIOR 8QC0 LOCAL
NOF wLD08
(Thu section need not be completed d the work involved TRwcr noO w ON LOT u.e zorvE aPEcuL commTIorva
by the permit is for one hundred dollars (SI00) or less) us¢ aP
BIZ6 OF LOT 6%I8 TIN0 0LDO
I certify that in the
naperformance of the work for which this �
—N.-
so asit Is to become subject to thnot e Workers' Compensation person any in Laws manrier oAN¢w /�
bJMwIL OCCUPANCY GROUP
JwDowlSa ;
Date Applicant LU
NOTICE TO APPLICANT If, after making this Certificate of CITY L Cj eTioL 1 OCCUPANT LOAD N
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 "A1L¢R U8¢ ❑ GEOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affrrn that I am licensed under provisions of Chapter1
9 (commencing with Section 7000) of Division 3 of the Bust- NO PEw MIr ❑ (LmT ITEMS ¢e Low) NO OF EXIT•
tress and Professions Code,and my license Is in full force and - --�
effect RKIN
PAG R6pD t� PwOV1D¢O I
SPACES
WKIN
License Number Lie Class I
- LIMITED TIME USE �
Contractor Date DATA DAT.
❑ 1 am exempt from the licensmg requirements as I am a
licensed architect or a registered professional engineer sI E OF INSP¢CTow s
acting in my professional capacity (Section 7051, Bus- Iannp eLDo SroRIES sip rupE
mess and Professions Code) FINAL APPROVAL q /� )
Lie or Reg No Date PR¢ae NT use oP eulLOlrvG G (p
HOME OWNER-BUILDER DECLARATION NO of EXISTING'BUILDINGS
ON Lor Coro uee #{ ' � � � 8 8 1
1 hereby affirm that I am exempt from the Contractor's _
License Law for the following reason (Section 7031 5, Buss- •
ness and Professions Code) NO PARKING
D1, as owner of the property, will do the work and the SPACES PROVIDED 1216-87
structure is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY Pw oros¢D USE OF Ru1LOINp
1 hereby affirm that there Is a construction lending agency 1 G
for the performance of the work for which this permit Is
Issued(Sec 3097,Civ C)
Lender's Name
PROPOSEO MAX OCC
Lender's Address
PERMIT P!! ouO
I certify that 1 have read this application and state that the
above Information is correct 1 agree to Comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL PEE fr�
on Ila above-mentioned properly for inspection purposes �21aa 0
A'J SEE REVERSE FOR EXPLANATORY LANGUAGE
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1 r 87
Signature of Permittee ate