Loading...
HomeMy Public PortalAbout4520TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION CE 875 - - MJ CELLANEOUS APPLICATION J—I CE 976 (11 941 r I I hee, o affirm that I have a certificate of consent to self COUNTY OF OS ANGELES BUILDING AND SAFETY DIVISION ,IL-III insure, or a copy thereo of Workers Compensation Insurance,or e certdied copy thereof(Sec 3800, Lab C) Policy No Company FOR APPL I CANT TO F I LL I N BUILDINGn „ -(/ 51 Certified copy is hereby furnished uDING wDDRE.e a� ooq¢Se LOCA LITV _ ElCertified copy u filed with the county budding inspection Aurr NE weesr department CRoes ET Date Applicant NEAREST oISTR j{Q /oI-L/ Trre eeeeo BY CRO.8 6T '/r �L CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Y COMPENSATION INSURANCE DUSCRIIT ION LOT No BLOCKMAP HIGHWA cI cLeY STATE MAJOR SECOND LOCAL NO OF BLOGB (This section Feed n0[ be completed If the Work InVOIVCd TRACT NOW ON LOT U8 ONQ SPCCIwL CO NDITIO N9 by the permit is for one hundred dollars ($100) or less) US¢ of 1 certify that in the performance of the work For which this SIZE OF LOT EXISTING BLDG I permit is Issued, I shall not employ any person in any manner ownER o� So, as to become subject to the Workers' Compensation Laws z MAIL OCCUPANCY GROUP _ o ADDRESS 14t$6 P4 6L4 P Date Applicant NOTICE TO APPLICANT If, after making this Certificate of Clrr NO - 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 provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl ❑ deemed revoked P LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Busr SAFETY PEw MIr ❑ (LIST ITEMS BELOW) NO OF EXITS ness and Professions Code,and my license is in full force and RrweEG effect PARKING REG o � PwoY[DBD License Number Lic Class LIMITED TIME USE Contractor Date A. DAT. I am exempt from the licensing requirements as I am a TD licensed architect or a registered professional engineer SIZE OF No oP INRPE CTOR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG sroglEE SwnwruwE mess and Professions Code) FINAL APPROVAL // Lic or Reg No PRESENT USK OF BUILDING 1 Date W'Z HOME OWNER-BUILDER DECLARATION n0 of EXIST[ G BYI DINGS O Y;j. � M4 FE ON Lor rano u.E Y I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busy V �QQ[I-DOQ1 6/17/9 ness and Professions Code) NO PARKING 0 I, as owner of thero rt will do the work and the SPACES PROVIDED I]jx i 1-:50P le y, Structure is not intended or offered for sale (Section - -- - 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit a issued(Sec 3097,Cw C) Lender's Name PROPOSED MAX Bee Lender's Address I certify that I have read this application and state that the PlRMIT FEE above information is Correct I agree to Comply with all County ISSUANCE P!! - ordinances relating to building Construction, and It reb author r ntattves of this County to enter TOTAL FEE upon the e-me o operty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE V ✓ / SI ture P it a me