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Home My Public Portal About4816TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION CE 875 LL MISCEANEOUSAPPLICATION {1 ,* 76 4 (21 64) LI I h&eby affirm that I have a certificate of consent to self COUNTY OF LOS ANf,EIES BUILDING AND SAFETY DIVISION insure, or a Certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FI LL IN no uwc sit �G Certified copy is hereby furnishedLolno ADOw Ha: • LOCAL." Certified copy is filed with the county building inspection gL,TY NHARHBT department CROIIII 6T Date Applicant NEAREST DISTRICT NO O oa• TYwe CHaSKD BY CwOIIH ST O 6 _� TYONST PE CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a COMPENSATION INSURANCE DESCwIPTIOn LOT NO aLo cK mNw AY I Nor ICIRCL.) STATE MAJOR SECOND LOCAL NO OF BLaOII (This SECItOn need AOI be completed If the work involved TRACT NOW ON LOT 1116 ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE or I ceSIZE Or LOT Hx1IIn No BLDGrtify [tut in the performance of the work for which this V � o permit is issued, I shall not employ any person in any manner OWNER arALIFAZ / V so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o ADDReSE Date Applicant �Z-6 -y �j w NOTICE TO APPLICANT If, after making this Certificate of CITY woL snAJ, , OCCUPANT LOAD a- Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- ❑ with Comply with such provisions or this permit shall be TRAILER us% ❑ GEOLOGY INSPECTION ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencuig with Section 7000) of Division 3 of the Busi- NO or EXITS ness and Professions Code, and my license is in full force and cgwa Cgs effect Pw wEINa REQ D t� PROVIDED BARW'N License Number Lic Class LIMITED TIME USE Contractor Date DAT. PAT. ❑ I am exempt from the licensing requirements as I am a rNON licensed architect or a registered professional engineer SIZE OF No oP INSPECTOR S acting in my professional capacity (Section 7051, Bus- EXISTING DLUa .Towles slG TUSH mess and Professions Code) FINAL APPROVAL )!�lU `� Lic or Reg No Date PRESENT USE OF BUILDING NO FE HOME OWNER-BUILDER DECLARATION NO OF EXISTING DUILDIN II e�w ON LOT AND USE •/-{l I hereby affirm that 1 am exempt from the Contractor's �/ 3 A10 /V� r� F/„' License Law for the following reason (Section 7031 5, Bust- ' / OIDOO—M t/ 6/?1 ness and Professions Code) NO PARKING ' I, as owner of the property, will do the work and the SPACES PROVIDED 1 Fh 114.] EJ structure is not intended or offered for sale (Section - 7044,Business and Professions Code) - CONSTRUCTION LENDING AGENCY PROPOSED USE or BUIYUNG I hereby affirm that there is a construction lending agency 1, G for the performance of the work for which this permit is issued(Sec 3097,Civ C) Lender s Name , PROPOSE MAX OCO Lender's Address I certify that 1 have Is apphatton and state that the PERMIT REE QU above intormatron u co ec[ gree to comply with all County ISSUANCE F e ordinance and State CosWas uddutg construction, and her a th ize ep this County to enter TOTAL FE b6 Iupon t a e- spectio pure sea SEE REVER E FOR EXPLANA Y LANGUAGE Si ature ot'Permitte ate