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