HomeMy Public PortalAbout4520TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION
CE 876(11 84)44 MISCELLANEOUS APPLICATION {�
CE LJ
I hoe,o Ia Cert that I have a s'Compensation
of consent to ,self
or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVIS N
insure, or a cert>Fgte of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800, Lab C) _
Policy No —Company FOR APP LICANT TO F I LL IN ¢uILOING u� T wvv¢es '7 /
Certified copy is hereby furnished BUILDING Saz� I£ �, L'�O
wvDR¢n IL CJS LOCALITY
Certified copy is filed with the county b ildung inspection wcwurY NEAREST '
department cno„ ar
Date Applicant NEARHST UlarRl T N GROur Trre enaso eY
c¢oSS ST Q 44" 2 /A S 1 l CONSr
CERTIFICATE OF EXEMPTION FRO WORKERS' LEGAL
COMPENSATION INSURA CE DESCRIPTION LOT No ¢LOCK IO NRwr a Are MAJOR SECOND wcwL
.M.o IGIRa.)
!�v
NO Or SLOGS -
(This section need not be completed I the work involved TRACT NOW ON Lor USE ZONE SPe CIAL CONDITION
by the permit is for one hundred It ars (5100) or less) _ _ LSE or _
SIZE or LOT EXISTING BLDG
1 certify that in the performance of t e work for winch this
permit is Issued, I shall not employ a person in any manner ownER / U
so as to become subject to the Work s Compensation Laws �+ /� /� OCCUPANCY' GROUP m
Date Apphcant MAIL
/4/
U
NOTICE TO APPLICANT If, aft making this Certificate of CIT. InOA1// NOL OCCUPANT LO/D d
Exemption, you should hem subject to the Workers' APPLICATION FOR EXIT HARDWation provisions of the box Code,you must forth- ❑
with comply with such provi ons or this permit shall be TRAILER USE ❑ a¢oLoav m,.HcnoK ❑ NO Spec AVEKnowl
deemed revoked ,
LICENSED CONTR ORS DECLARATION OCCUPANCY INSPECTION[�- Panic Vices
1 hereby affirm that I am It used under provisions of Chapter -
9 (Commencing with Secti 7000) of Division 3 of the Bust SAFETY PERMIT ❑ (LIST ITEMS BLOW( No o EXIT,
ness and Professions Code and my license is in full force and
effect PKING
arwARc¢S D D � PR oviO¢D
License Number Lic Class
LIMITED TIME USE
Contractor Date O.T. O.T.
I am exempt f in the licensing requirements as I am a
licensed archi ct or a registered professional engineer SIZE orrvo or INSPECTOR ,
acting in my rofemonal capacity (Section 7051, Bus- EXISTING BLDG STORIES _ ,IarvAru RE
messand Pro ssions Code) FINAL APPROVAL
Lie or Reg No Date PRESENT USE or BUILVIna
HOM OWNER-BUILDER DECLARATION no OF RXISTING BUILDINGS s (y. IJQQI�-QQI�l d/ 'J�yi
ON LOT AND USE
I hereby aff m that I am exempt from the Contractor's _ 04, 6092U� 1
LicenseLaw for the following reason (Section 7031 5, Bust-
/I 4 ,
nessandl) essions Code) No PARKING
1, as wner of the property, will do the work and the Srwc¢S PROVIDED - I
struc re is not intended or offered for sale (Section
704 ,Busmess and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE Or BUILDING yL ,L
1 here affirm that there is a construction lending agency
for performance of the work for which this permit is
issued Sec 3097,Cry C)
Lender s Name
PROPOSED MAX OCC
Lender's Address �l
PERMIT PEE p\ /
I certify that I have read this application and state that the
above information is correct 1 agree to comply with all County ISSUANCE PEE
ordinances and State laws relating to budding Construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon t above
e--mentioned r/oy/Q(/gty for inssspeeccyos,Fugyp,ores SEE REVERSE FOR EXPLANATORY LANGUAGE _
Yol...� lee I�L�L to /9/
tore of Permittee� — dater �