HomeMy Public PortalAbout4812TEMPLE CITY BLVD_Miscellaneous WORKERS COMPEtgSAT10N'DECLARATION
CE 875(11 64) M ISCELLANEOUS APPLICATION JJJ���III
CE 676 1� I
I hereby affirm that 1 have cermpof consent to self - COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IILJI'
insurer or a certificate oCWorkars'Compensation Insurance,or � ,
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING p
ADDRESS O rr
FICertified copy is hereby furnished BUILDING /� G
wDD...S LOcwurr
0 Certified copy is Filed with the county budding inspection LOCALITY NEA . T
department cwoaS ST (A—)L
Date Applicant NEAREST 1 'I DISTRICT NO a Tr PE P c¢a Der
CROS RT (�('�/� QaG45 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK Iaewwr
NOP Ic1 CLS) SrwrE Nwrow ¢co ND LoewL
NO OF BLOGS
(Thu section need not be completed d the work involved • rwwcr now ONLor USE zone SPEnwL CONDITIONS I
by the permit is for one hundred dollars ($I00) or less) _ USE or
I Certify that m the performance of the work for which this SIZE oP Lor exlannG BLDG - o
permit is issued, I shall not employ any person in an manner
w as to become subject to the Workers Compensation Laws w oi�,�ee
LT�FC�K I OCCUPANCY GROUP o
• woow Ess (y('�jc:a
Date Applicant O , m
NOTICE TO APPLICANT If, after making this Certificate of • CITYLOS A06 7i woL 2.( 6 I OCCUPANT LOAD
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 beiEl No Spec KnOwl
deemed revoked TRAILER USE ❑ a¢oLoor INSPECTION El
LICENSED CONTRACTORS DECLARATION occurwncr INavecnoN Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter
9 (Commencing with Section 7000) of Division 3 of the Bust awP¢rr P¢RNI ❑ (LIST ITEMS Below)
No OF ¢xlTa
ness and Professions Code, and my hcense is in full force and /� 19�uS
effect P PARKING RED PROVIDED
License Numher Lmc Class E- L—
ePwcES
'44
tt LIMITED TIME USE
Contractor Date DATE DAT.
❑ 1 am exempt from the licensing requirements as I am a D
To
hcensed architect or a registered professional engineer SIZE IF w u NO or INSPECTOR S
acting m my professional capacity (Section 7051, Bus- EXISTING BLDG �' STORIES I SlGnwruwB
mess and Professions Code) FINAL APPROVAL
Lw or Reg No Date PRESENT USK OF BUILDING . (—
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS / N13 F
ON LOT AND VSE-N
I hereby affrim that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Bust Y t ���Qi 2/12/1r,ness and Professions Code) NO PARKING �.rl�
El I, as owner of the property, will do the work and the 1, SO
PROVIDED ELMS ] Fri IMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING R„
I hereby affirm that there is a construction lending agency '
for the performance of the work for which this permitiy f�
issued(Sec 3097,Cry C) /
Lender's Name
• PROPOSED MAX Dec
Lender's Address (d ,
PERMIT FfiE
00
I certify that I have read this application and site that the 1(Ir-,fl`o
above information is correct I agree to Comply with all County ISSUANCE FEE
ordinances and State laws relating to budding construction,
d
and hereby authorize representatives of this County to enter TOTAL REE
on the above-mentio d property for ectio urposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Stgnatu o rmmttee Date