HomeMy Public PortalAbout4812TEMPLE CITY BLVD_Miscellaneous (2) WORKERS COMPENSATION DECLARATION
CE 875 (2 80) MISCELLANEOUS APPLICATION
CE 875
1.icrreby atfirrrr that I nate a certificate of consent to Self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
IIV�ire.or a cerIV4cate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C )
Policy Nc, Company FOR APPLICANT TO FILL IN EUILDING
ADDRESS
❑ Certified copy Is hereby furnished C LOCALITY
12
❑ Certified copy a filed with the county building inspection NEAREST
department LOCALITY CROSS aT
I
Dale Applicant BT
CROSS 9T OISTRIC NO OUP TCYPE C as KD BY
R09a ON9T
f4 44-3
CERTIFICATE OE EXEMPTION TROM WORKERS Deec RIPTION L b 3� awc% D JJ
COMPENSATION INSURANCE .MioP (j jc�.cW el STATE MAJOR SECOND AL
(This section need not be completed If the work mvolved N OF SILDGe uaK xoNK sP eclwL conDlnoNe
p TRACT NOW ON LOT O
by the permit Is for one hundred dollars ($100) or less) L)
uee TINGI certifythat In the a of LOT ExlanIaLDe cc
performance of.the work for which this 0
permit Is Issued 1 shall not employ any person In any manner OWNER A4eF.
so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP _ U
MAIL
DOREBa W
Date Applicant _ N
NOTICE TO APPLICANT If after making this Certificate of CITY OL OCCUPANT LOAD Z
Exemption you should become ,subject to the Workers qpp LIGATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth
with comply with such provaions or this permit shall be TRAILER ueeeeoLoar INSPECTION
deemed revoked ❑ ❑ No Spec Knowl ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION MK Panic Devices ❑
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT q (Liar ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Bust
ness and Professions Code and my license Is In full force and
effect I (cant's Name — IrO
a w ea RED D PROvIDeD
License Number Lic Class None Address - d'
Contractor Date IRO. ..TLIMITED TIME USE RwTe
El : em exempt from the licensing requirements as I am a Phone — '
censl.d architect or a registered professional engineer SIZE OFNo oR INSPECTOR S
acting in my professional capacity (Section 7051 Bus- EXISTING DLDG erDelEe SIC% TURK
Dass and Professions Code) _
P fi9E NT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION NO OF e%ISTINO BUILDINGSL.Jn ""'J�'�
ON LOT AND USE �
I hereby affum that 1 am exempt from the Contractors ✓�� d 0�,
License Law for the following reason (Section 7031 5 Busl �
nessLir
ness and Professions Code) No PwR%Inc �
SPACES 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) PROPOSEO USE OF BUILDine — T I 84, 5A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency # . . . . 4 0
for the performance of the work for which this permit Is
Issued (Sec 3097 Civ C) ` # (l O
Lender s Name
PROPOSED MAX OCC
Lender a Address
PERMIT FEE
I certify that I have read this application and state that the a 2 1 _8 0
above Information is correct I agree to comply with all County ISSUANCE FE ,
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authorize representatives of this County to enter
xup/oA/ry/s'tnhe/above ntlone pro y for Inspection pur'pos'es SEE RF VERSE F XPLANATORY LANGUAGE
��� a
Signature of Permittee Da