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
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SI ture P it a me