HomeMy Public PortalAbout4816TEMPLE CITY BLVD_Miscellaneous (2) WGIRKERS'COMPENSATION DECLARATION 7SM444 �'
CE 875 (280) M ISCELL- ANEOUS1APPLICATION
1 Hereby afflrrt that 1 neve a certificate of coresent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a copy
there of Workers Compensation Insurance or
a certified copy thereof(Sec 3800,Lab C )
Policy No Company FOR APPLICANT TO FILL IN
E] emLDING
woORcas
Certified copy is hereby furnished uuowG
❑ woDR /6 iPr 'e /
LOCALITY
Certified copy is fled with the county budding inspection
department ewLiry _V-;�rM J NE REST
CnovS ST
Date ApplicantREST Oiarnwr N aRuP T PRo eo BY
-ROSS ST �- .C`D �� co aT
CERTIFICATE OI EXEMPTION FROM WORKERS LEGAL s
COMPENSATION INSURANCE DEvc Rirnon Lor No BLOCK ICNvrw }a
IND or aLDaa
ROP (e,RCLKI STATE MAJOR SVC o LOCAL
(This section
rm need not be hndredcompleted if the work myotvedless) rnwcT Now F LOT eve: zone aPEuwL co No mons
by the permit is for one hundred dollars (5100) or less) eve of
1 certifythat in the SIZE of LOT Ex ISTiNG BLDG
performance of the work for which this Q
permit is issued I shall not employ any person in any manner R >Q l• S
so as to become subject to the Workers Compensation Lesys OCCUPANCY GROUP W
DRESS N
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of v -e-;e-telTKL OCCUPANT LOAD z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth APPLICATION FOR EXIT HARDWARE
,j with comply with such
p y provisions or this permit shell be rR aiL¢R USE - eeoLoav INSPECTION deemed revoked ❑ ❑ NO Spec KnoWl El
LICENSED CONTRACTORS DECLARATION
occuPANCV INSPECTION Panic Devices
El
I hereby affirm that I am hLensed under provisions of Chapter SAFETY PERMIT ❑ (LIST NEMS BELOW) NO OF EXIT$
9 (commencing with Section 7000)of Division 3 of the Bust
ness and Professions Code and my license is in full force and ..
effect . PARKING
SPACER REG D O PROVIDED
License Number Lie Class LIMITED TIME USE
Contractor Date o.Te ..TV
1 am exempt from the licensing requirements as I am a ,
licensed architect or a registered professional engineer SIZE orno or INSPECTOR a
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG arovtea a)6NATURE
meas and Professions Code) FINAL APPROVAL 4
r ENT uaE or BUILDING
Lie or Reg No Date
HOME OWNER BUILDER DECLARATION No OF EXISTI.QFBUILD.NDS S S S S S S It SQ
ON LOT AND BSE
I hereby affirm that I am exempt from the Contractors 12, ']"8 S
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING
SPA cKill PROVIDED
I, 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) oe ED USE of BUILDING
CONSTRUCTION LLNDING AGENCY �j /
I hereby affirm that there is a construction lending agency IC G ^
for the performance of the work for which this permit Is U
issued (Sec 3097 Civ C) -
LLndersName PRorosro MAX Dec � f/
Lender's Address PERMIT FEE _
I certify that I have read this application and state that the C
above information is correct I agree to comply with all County ISSUANCE FEE
-ordinances and State laws relating to budding construction TOTAL FEE
and hereby authorize representatives of this County to enter
upon the above poorio d r arty for inspection urpuses SEE REVERSE. FOR EXPLANATORY LANGUAGE
Signature of Per- rmttee Date