HomeMy Public PortalAbout4805TEMPLE CITY BLVD_Miscellaneous WORKERS'OOMPENSATIONDECLARATION CE 875(71 84) - MISCELLANEOUS APPLICATION {�
CE 875 Ll
I here, o aflvm'that t have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C) p
Policy No Company FOR APPLICANT TO FI LL IN wDDweQs p�S
Certified copy is hereby furnishedeu uolNG p OY g, /t LOcw urr
•DOR 66n 8 Dsyk
Certified copy is filed with the county budduig inspection ocwLlTv Ne RAREST
department e'y1 ( cRAR ST
Date Applicant NEAREST J DISTRICT NO GROUP IT PQ RROCHal6D OY
CgOnB QT Lo*u R-V' v-sm- �� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DewcwIPTION LOT No BLOCK .ORIvw
Nem
NO OF BLO68 (cI CLw) STATE MAJOR SECOND LOCAL
(Chis section need not be completed d the work involved TRACT now ON LOT Use ZONE ngecuL conDlnoNw
by the permit is for one hundred dollars (SI00) or less) USE or
SIZE OF LOT H%ISTING BLDG C
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any maturer OwNER e�LL4�ie. oL u co
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o
Date Applicant AODRewn 6dd
nn U
NOTICE TO APPLICANT If, after making this Certificate of c1Tv LC t'pfd, C.0. no�,/3�6 9 OCCUPANT LOAD o_
Exemptwn, you should become subject to the Workers'
Compensahon provinons of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE ❑
deemed revoked GEOLOGY INSPECTION NO Spec KnoWl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] Panic Devices
I hereby affirm that I am hceneed under provisions of Chapter swFErr PERMIT' (LIST ITEMS BELGA(
9 (commencing with Section 7000) of Division 3 of the Busr NO OF EXITS
ness and Professions Code, and my license is in full force and
effect PARI
PwCKEN-n REO D � PROVIDE-
S
License Number Lic Class O
LIMITED TIME USE
Contractor - Date-
0
ate❑ 1 am exempt from the licensing requirements as I am a RDN Te
hoensed architect or a registered professional engineer SIZE OFNo of INSPECTOR n
acting in my professional capacity (Section 7051, Bus- EXISTING BLOC aroRles slGnwruge
mess and Professions Code) FINAL APPROVAL
Lie or Reg No Date PRESENT USE OF EUILDING
HOME OWNER-BUILDER DECLARATION NO OF E%ISTING BUILDINGS O F"EE
ON LOT AND USe
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busr �, _'60-Iilyl
ness and Professions Code) NO PARKING �r�
1, as owner of the property, will do the work and the SPACES PROVIDED 4h -
N4 i;4'1
structure is not intended or offered for sale (Section I
7044,Business and Profewons Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING _
I hereby affirm that there is a construction lending agency Ji, P-eS'7�"GwrJho�ra
for the performance of the work for which this permit is
issued(Sec 3097,Civ C)
Lender's Name
PROPOSED MAX OCC
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL FEE 01,5700
upon the abo e-mentionedperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofKennittee ate