HomeMy Public PortalAbout4516TEMPLE CITY BLVD_Miscellaneous (2) WQRKERS'COMPENSATIONDECLARATION CE 8754"
(2 MISCELLANEOUS APPLICATION
I hereby affirm that 1 neve a certificate
ompen of consent Insur 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)
Policy No Companj FOR APPLICANT TO FILL IN BUILDING ADD / r
❑ Certified copy Is hereby furnished Bonwe
Locwury
Certified copy u filed with the county budding inspection ./ LOCALITY
r q
IF
department Lo ALrrr /��� C C-4 /28'0cRoas ar ^+
Date Applicant EAREST J�'I/�/f alar Rl/��rr��Io 0 ouP rr Pe Peoc s ¢o er
CRO s¢ aT Y�V r�F'� C(I.WJ C V (� CONSTI
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J t
COMPENSATION INSURANCE Dcsc Rion oN Lor No BLOCK MAP rl Iawwwv s }
STATE MAJOR SEC 0
dollarsLOCAL a
(Thus section need not be completed of the work involved No NOW ON LOT OP OLDca uae zorve aPEcuL conoiTlorva O
TRACT U
by the permit Is for one hundred dors (5100) or less) use OF
1 certifythat m the sine OF LOT ex„TING BLDG W
performance of the work for which this
permit is issued, 1 shall not employ any person in any manner OWNER O
so as to become subject to the Workers Compensation LawsAIL OCCUPANCY GROUP W
use CL
Date Applicant - p,`/� /� o � � — Z
NOTICE TO APPLICANT If after making this Certificate of CITY �/yf/7�(/� VJy oL OCCUPANT LOAD
Exemption you should become subject I the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth
with comply vnth such provisions or this permit shall be TRAILER uae GEOLOGY INSPECTION
deemed revoked r ❑ ❑ No Spec Knowl ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT (UST ITEMS BeLowl no OF extra
9 (commencing with Section 7000) of Division 3 of the Busi
ness and Professions Code end my license is in full force and ` PA RxINa
effect
SPACES RED D E= PROVIDED
License Number Lic Class LIMITED TIME USE
Contractor IData oATR GATS
❑ Pwow
I em exempt from the licensing requirements as 1 am n
hcenxd architect or a registered profesoonal engineer Size o No oP Ines crow S
acting m my professional capacity (Section 7051 Bus- Sx InG BLDG 300 SQ• s N0 OF
Gewru Re
mess and Professions Code) PReaeNT USE OF BUILDING ✓�.Gh 4-T FINAL APPROVAL
Lic or Ret; No Date
HOME OWNER BUILDER DECLARATION
P EXISTING BuiI.Dlrvaa
LOT AN
u86
I hereby affirm that I em exempt from the Contractors
P359,5A
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING # • • • • 8 8
•PAC6e PROvIO%D
ID1, as owner of the property will the work end the . . . . B • ,
structure Is not intended or offered for sale (Section
7044 Business and Professions Code)
oPOSCD USE Or BUILDING JQO�i6r/z
CONSTRUCTION LENDING AGENCY
I hereby iffum that there is a construction lending agency '
for the performance of the work for which this permit is
issued (Sec 3097 Civ C) ”
Lenders Name PROPOaeo MAX OCC 1 1�
Lender's Address PERMIT PEE 1nYA\(Y
I certify that 1 have read this application and state-that the
above information is correct 1 agree to comply with all Count) ISSUANCE FEE
ordma s and State laws relating to building construction TOTAL Fee
and er y eu[hor 7e repr tatives of this County to enter ,
up t bove In to try for msE$Q4Qon purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
/iggnatcure(off,..PPff//rmfot tee Date