HomeMy Public PortalAbout4805TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DLCLARATION 76M444 `
CE 876 (11 84) M ISCELL ATION {�
1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES AND SAFETY DIVISION L1
insure, or a certificate of Workers'Compensation Insurance or
a certified copy thereof(Sec 3800,Lab C) �- `
Policy No . Company ' FOR APPLICANT TO FILL IN , wo'o`, D
DDRI 0 �r
Certified copy is hereby furnished Bu ON D C LD i LOCALITY
ese
Certified copy is filed with the county budding inspection LOCALITY .L'J NRARSST
department Ci� •711 `J�' 7_14R corona eT
Date Applicant NQARQQT DISTRICT NO O OUP TYPE CHBIQD BY
CRO/9 IIT O COn ST
CERTIrlCATE OF EXEMPTION FROM WORKERS LEGAL ap
COMPENSATION INSURANCE GEe CR IPr1ON LOT no BLOCXP .Ian.
no (uw.,.) STATE MAJOR .HCONO LOCAL
NO Or SLOGS
(This Section need not be completed If the work involved TRACT NOW ON LOTUtE ZONA CPE CIAL CONDITIONS
by the permit Is for one hundred dollars ($I00) or less) UEExl Or -
I certify that in the performance of the work for which this
usE OP LOT a .TING BLDG o
permit is issued, I shall not employ any person many manner OWNER of b!Aiq4.1UR. DMO0 v
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP
Dale Applicant oDREeEA P. 1 O b d W
NOTICE TO APPLICANT If, after making this Certificate of CITY 1 PACU xoL I- a OCCUPANT LOAD h
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- _ APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be ❑ ❑ No Spec Knowl
deemed revoked TRAILER USE oeo Loot INErecnoN
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 Busy EAF2TY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code, and my license Is in full force and
effect Name of business : PARKING
SPACES RED O D PROMOED D
License Number Lic Class
LIMITED TIME USE
Contractor Date AT. T.
FlI am exempt from the licensing requirements as I am a P.oM
licensed architect or-a registered professional engineer SIZE orNo or INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
men and Professions Code) O FINAL APPROVAL �2i.96 ale
Lic or Reg No Data RERQNT USE Or BUILDING
HOME OWNER-BUILDER DECLARATION _ NO Or EXISTING BUILDINGS OY_f FEE
ON LOT ANG USE
I hereby affirm that'l am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi
ness and Professions Code) NO PARKING33
ffyy
1, as owner of the property, will do the work and the EPAceE PROVIDED ) 0 111:
structure is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY CROPOSED USE Or BUILDING
1 hereby affi n that there is a constmctron lending agency �y
for the performance of the work for which this permit is
issued(Sec 3097,Cry C)
Lender s Name 614
PROPOSED MAX OCC
Lender's Address
1 certify that I have read this application and state that the PERMIT FEE 25 . 00
above information is correct 1 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 FEE25 . 00
-
upon the above-mentioned pr perty for nspecti purpose101 L�s
SEE REVERSE FOR EXPLANATORY LANGUAGE
If Soutture of Pont Itt;e ` ate