HomeMy Public PortalAbout4522TEMPLE CITY BLVD_Miscellaneous WORKERS'COAIPENSATION DECLARATION
CE 875 (11 641 MISCELLANEOUS APPLICATION
CE 876 �I
1 hereby a finncert that 1 have a s'Compensation
of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �Iuli
insure,-or a cerfilltste of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BmLDINa ��
ADDRees
Certified copy is hereby furnished BDIw INS �L /
u filed wD Ow eee LOCALITY
Certified copy led with the county building inspection12
NEAREST
department CROSS ST
Date Applicant NEAREST DISTRICT NO anour TrrE eee EO IS
CROSS eT _� co NS
oT
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'Q
COMPENSATION INSURANCE DXSCR IPTrON LOT No eLDCK aTwre MAJOR SECOND wcwL
('this section need not be completed if the Work involved TRACT I NO OF LOGS MOW ON LOT nS[ ZONE SrS CIALRCONDITIONS
by the permit ts for one hundred dollars ($100) or less) lug OF Or
I certify that in the performance of the work for which this wiz¢ or LOT exlanna BLDG
permit is issued, 1 shall not employ an person in an manner I U W n to
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Pe P Y Y P Y ovnEw
so as to become subject to the Workers Compensation Laws ( , OCCUPANCY GROUPMAIL
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AD DR CBS X Q m QJ`�/'1 O
Date Applicant L /�,y� /� .� / w
NOTICE TO APPLICANT If, after making this Certificate of CITY ne mo T NOL CIM ILL
- S - 681 OCCUPANT LOAD a
Exemption, you should become subject to the Workers' rn
Compensation provisions of the labor Code, you must forth
APPLICATION FOR EXIT HARDWARE z
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec KnoWl ❑
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with Section 7000) of Division 3 of the Busy ❑ (UST ITEMS ee Loiv) NO OF EXITS
ness and Professions Code,and my license u in full force and
effect MOjIv C ` : HE
SPACES RED FROVIDED .
License Number Lie Class
LIMITED TIME USE
Contractor - Date - DATA DAT¢
DOM O
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE or No ow INSPECTOR [
acting m my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
/m NATURE
mess and Professions Code) Q FINAL APPROVAL 5_27-93 /v
Lie or Reg No Date PRESENT tie¢ or BUILDING
HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS (A J P40 FEE
ON LOT AND USE O -1
I hereby affirm that I am exempt from the Contractor'sr _
License Law for the following reason (Section 7031 5, Bust / -,(y _ ul]QQ-0001 5/ J/9�
ness and Professions Code) NO PARKING / ll'
1, as owner of the property, will do the work and the SPACES PROVIDED 9502 1 All 9:2s
structure is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affurn that there is a construction lending agency YI ^rCL.I
for the performance of the work for which Ilia permit is '
issued(Sec 3097,Civ C)
Lender's Name -
PROPOSED MAX Bee
Lender's Address
PERMIT FEE (N
I certify that I have read this apphctnon and state that the
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEEV
upon the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date