HomeMy Public PortalAbout4522TEMPLE CITY BLVD_Miscellaneous (2) WORKERS COMPENSATION DECLARATION Cr75 (2 801
MISCELLANEOUS APPLICATION
C 875
1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a cef;nccate of Workers Compensation Insurance or
a certified copy thereof fSec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDINGas
ADORNS•
❑ Certified copy Is hereby furnished DU.LOING --�� r/ _
AOORHm,
F1I��Ifj CIl �fd el Loc wurY
Certified copy a filed with the county budding Inspection B�
department LOCALITY neweear NEARE Sr
Date Applicant NEAREST Dle /:p ['OUPry P¢
P ¢SSE. RY
OROE9 9T J.0U) 2i,"ou
CERTIFICATE OI EXEMPTION FROM WORKERS LEGAL CONE
COMPENSATION INSURANCE OEECRvnoN Lor no awcX rMieA (I....) STATE MAJOR SECOND LOCAL d
No OF SLOGS ` Q
(This section need not be completed if the work involved TRACT now On LOTr USE
zone evectAL CONDITIONS U
by the permit is for one hundred dollars (5100) or less)
ue¢ TINGmzc OF Lor ¢xisnBLDG I 0
OF
I certify that m the performance of the work for which this 0
permit a Issued I shall not employ any person in any manner OWN¢ U
so as to become subject to the Workers Compensation Lasys MAIL OCCUPANCY GROUP LU
wODR¢a / q, y. h
Dale Applicant Z
NOTICE TO APPLICANT If after making this Certificate of ciTr art n� Tri
TEL
/ 635— 6 OCCUPANT LOAD
Exemption you should become subject to the Workers
Compensation provisions of the Lebo, Code you must forth APPLICATION FOR EXIT HARDWARE
with comply with _such provisions or this permit shall be TRAILER use aeO LOav INevecnon
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPIJ noN ❑ Panic Devices ❑
I hereby affirm that 1 am Imensed under provisions of Chapter SAFETY P¢RMI (LIST IT¢M. BELOW) NO OP 9XIT5
9 (commencing with Section 7000) of Division 3 of the Bust `
ness and Professions Code, and my license is in full force and vARNine
effect ^ /j SPACES REO D � PRovIDED
License Number Lic Class `� /1 4-C /'
LIMITED TIME USE
Contractor Date OATS GATE
TO
❑ 1 am exempt from the licensing -equirements as 1 em a
licensed architect or a registered professional engineer SIZE OF nO OF INSPECTOR S
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES S.qVATUR9
iness and Professions Code) FINAL APPROVAL _
PRESENT USE OF BUILDING K
Lic or Reg No Date-
HOMEOWNER
ateHOMEOWNER BUILDER DECLARATION no OF EXISTING BUILDINGSON Lor AND USE 4g �IQI dl—I_I]IJ1 ii I. 14/ '1
1 hereby affirm that 1 am exempt from the Contractors19 L 9471 1 till 7%2;
���
License Law for the following reason (Section 7031 5 Bust fY I
ness and Professions Code) NO PARKINS
❑ roSPAe¢s PROVIDED
1 as owner of the property will do the work and the
structure is not intended or offered for sale (Section
7044 Business and Professions Code) PROPOSED USE OF SUILain
I CONSTRUCTION LENDING AGENCY f�
I hereby affirm that there is a constrULttun lending agency tJ
for the performance of the work for which this permit is
Issued(Sec 3097 Civ C)
Lender s Nam
PROPOSED MAX OCC
Lender a Address PERMIT FEE
I certify that t have read this application and state that the
aboxc information Is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authonre representatives of this County to enter
;2e t e above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
to r 4 _ of 1' - — 9/
Signature of Permittee Date