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HomeMy Public PortalAbout4518TEMPLE CITY BLVD_Miscellaneous WORKERS COMPENSATION DECLARATION , CE 876 (2 80) MISCELLANEOUS APPLICATION {I CE 876 �J 1 hereby affirm that I hese a certificate of consent to self COUNTY OF LOS ANGELES B16ILDING AND SAFETY DIVISION Insure or a certificate of Workers'Compensation Insurance,or a certified copy thereof(See 3800, Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ❑ �j ADDRESS ✓/r Certified copy u hereby furnished wo ort Rna -(� CM ( V LOCA Tv Certified copy u filed with the county budding inspection NEA REST department LOCALITY , CROSSST Date Applicant ROR¢¢r ' ww^� ��{ DISTRICT No elrouP TYr¢ r ¢eneD BY ' CROnR !T�r�J C. I O a f CONSY CLRTI FICATE OF EXEMPTION FROM WORKERS LEGAL o i/ COMPENSATION INSURANCE D¢SC RI LT LOT LOT NO' -LOOKr Y. IDRA "} TL TRACT Ho (CIRCLE) STATE MAJOR SECOND LOCAL a (Thu Section need not be completed If the work involved rvo oP SLOGS USK ZONE nPCCIAL CGNDITIONn O NOW ON LOT OF L) by the permit is for one hundred dollars ($I00) or less) USE TING1 certifythat In the arse oP LOT cwanBLOC _ �7 O performance of ilia work for which This S" permit D Issued I shall not employ any person In any manner wrv¢R O ® U so as to become subject to the Workers Compensation Laws MAIL i�j-17 tl t ) e yj 1 OCCUPANCY GROUP W Al ADDRBsn �`11SS _1 V {.J 0 a Date Applicant b N NOTICE TO APPLICANT If after making this Certificate of t,,?.ii t s �L �� '3S�'�a 7 OCCUPANT LOAD Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forth APP LICAT R EXIT HAR DCWARE with comply with such provisions or this permit shall be TRAILER USE C] GEOLOGY INSPECTION deemed revoked ED Spec No p Knowl El LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 0 Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS 9 (commencing with Section d my is nseDivis in 3 ll the Bust ness and Professions Code and my license Is in full force and de PARKING effect SrACEe ReOO E= PROVIDED License Number Lic Class M CA net 00 t LIMITER TIME USE Contractor Date awr¢ D.Y. El1 am exempt from the bcensing equlrements as I am a licensed architect or a registered professional englreer SIZE ofrvo Rot INSPECTOR'$ acting in my professional capacity (Section 7051 Bus- EXISTING BLDG aro RIPS SIGNATURE mess and Professions Code) rx¢aENT u$¢ of BuumrvG FINAL APPROVAL Ls or Reg No Date- � 1 A e ah 110-3411 NO ., EXISTING BUILDINGS 11 HOME HOME OWNER BUILDER DECLARATION ON LOT AND u$E ' I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Bust 0 41 Ill r ness and Professions Code) No PARKING �VU-Valli d117rj1 SPACES PROVIDED n6 1 as owner of the property well the work end the F� :� a structure not intended or offered L- d for sale (Section ` 7044 Business and Professions Code) rnoroneD BE of BUILDING ` CONSTRUCTION LENDING AGENCY e'r QOO I'y� .J 0 SUP JJ I hereby affirm that there is a construction lending agency for the performance of the work'for which this permit is Issued(Sec 3097 Civ C ) Lender s Name PROPOSED MAX OCC Lenders Address PERMIT FEE a i I certify that I have read this application and state that the above Information Is correct I agree to comply with all County ISSUANCE FEE _ orit n ces and Ste[ a ting to budding construction TOTAL FEE and reby author. r es fives of this County to enter the above me lI p perry for Inspect n rposes SEE REVERSE FOR EXPLANATORY LANGUAGE i9 q SlIgnature of Permittee I Dat