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Home My Public Portal About4518TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION 78M444 MISCELLANEOUS APPLICATION CE 075(11 841 1 hereby affirm that 1 have a s'Co of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a certdiate of Workers Compensation sation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN Certified copy a hereby furnished -mLDmG XX woos¢SS 4S/ N TP.IIA '(! IVd LOCALITY Certified copy is flied with the county building inspection LacALlrr NEAREST department XX CROSS ST Dale Applicant NEAREST 0ierwicr no GROUP TYPE / C¢SS[o By CROS. ST D (� CON.T/� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGwL A COMPENSATION INSURANCE oE=TLION Lor no -LOCK Mor jclwc ail STATE MAJOR SECOND LOCAL no or BUDGE, (Tho section need not be completed d the work involved TRACT now ON LOT USE ZONESPE eIwL co no ITIONS by the permit s for one hundred dollars ($I00) or less.) USE or // 2 SIZE Or LOT [FI/TING 1111.00L "/ _ 1 certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person in any manner OWNER of building cA —Y I Lo so as to become subject to the Worker' Compensation Laws MAIL a OCCUPANCY GROUP J o Date Applicant wo DLO ESS 4r/0 AJ TG..+P1! Gby 6111Y s.r U NOTICE TO APPLICANT If, after making this Certificate of CITY 7't, fJIL C,/+"J noL 1g ) pr{z - 04 I`2 OCCUPANT LOAD o_ 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 provmons or this permit shall be deemed revoked rwwiLEs us[ C] GEOLOGY INSPECTION❑ No Sc KnoWlEl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Section 7000)of Division 3 of the Busy NO Err •ERMrt E] (LOST ITEMS BELOW) No or EXITS cress and Professions Code,and my license am full force a effect Name of business SO SPACES REG O L___j PwonoeD License Number Lnc Class YA WA ( AZz Llt'Aeo LIMITED TIME USE Contractor Date DATA AT. I am exempt from the licensing requirements as 1 am a T. IIIOw licensed architect or a registered professional engineer SIZE or No or INSPECTOR s acting m my professional Capacity (Section 7051, Bus- EXISTING -LOG STowles SIGN RE mess and Professions Code) FINAL APPROVAL Lic or Reg No Date PRESENT USE or BUILDING (- HOME OWNER-BUILDER DECLARATION no Or EXISTING BUILDINGS I �O h� ON LOT AND USE I �/1 I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5, Burr � ness and Professions Code) NO PARKING I, as owner of thePe ro rt will do the work and the SPACES PROVIDED P structure IS o not intended or offered for We (Section 7044 Busmess and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING I bereb) affirm that there is a Construction lending agency for the performance of the work for which this permit o nsued(Sec 3097 Cry C) - Lender s Name I k.1y PROPOSED MAX Dec i Lender s Address I certify that I have rad this application and state that the PERMIT FEE above information is Correct I agree to comply with all County ISSUANCE FEE orduumms and State laws relating to building construction, 1'171 and hereby authorize representatives of this County to enter TOTAL FEE 25- 00 upon the abevc-mentioned property for inspection purposes XX , + �O,, < XX3 6 SEE REVERSE FOR EXPLANATORY LANGUAGE /5S' '` O Slgmlurc of Pennittee Date y• '�