HomeMy Public PortalAbout5703TEMPLE CITY BLVD_Miscellaneous (2) 11UMIM, LU\IP1.NbALIUN UtULAKAIIUN MISCELLANEOUS APPLICATION
CE 875(11 841 C
I hereby aAum that l hale Certificateof consent to ser COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
mstire, or a Certificate of Workers Compensation
Compensation Insurance,or
a certified co j - sec 380SL3p )� / [ulLn lNo
Policy No mpanv TT/R+ FOR APPLICANT TO FILL IN �0
�1 wODwcas
EaCertdied cap) is hereby furnished [UILDI"c �. 5703 C! U Locw Llrr
ADDRcxs
gi
Certified copy is filed with the county budding inspection 'LOCALITY / l.. NEAR EST
department cwoaa aT
Date Applicant I CROSS IT �-�. (V� DlarRl Vo owgq"uP
7 cwoaa e- ✓�IV e �L(.N O G /{ COConar
CERTIFICATE OF EXEMPTION FROM R'ORKERSLecwL C �d
COMPENSATION INSURANCE } ocacRnn oN LOT NO Bloc% .c jcwcLsj STATE MAJOR SECOND LOCAL
/-�y rv0 OF BLDaa
`. m Section need not be completed 1f the work mSolved I TRACT NON oN LOT USE SOrv[ sPeelwL CONDITIONS
by the permit is for one hundred dollars IS 100) or less) I uSe or
1612[ Oi LOT E%16TING BLDG
1 certif) that in the performance of the work for which this c =_
permit is issued 1 shall not emplos an) person in any manner XI Ov NeR Q,NIQ/� /wo-n- Qq
m as to become subject to the INo•kers' Compensation Leas MAIL OCCU'ANCY GROUP
Date Applicant
NOTICE TO APPLICANT If, after making this Certificate of I CITY NOL N./ OCCUPANT LOAD -_
Exemption, )ou should become subject to the Yorkers _
Compensation pros icons of the Labor Code, sou must forth APPLICATION FOR EXIT Hr,RDWARE
with comply with sucn provisions or this permit shall be ❑ a¢oLD cr INSPECTION ❑ No Spec Knowl
deemed resoled TRwus+ un¢
LICENSED CONTRACTORS DECL ARATIO\ OCCOFANCV INSPKCIIONZ Panic Devices
I herebs affirm .ha I am licensed under prosislons of Chapter
9 (commencing urth Section 70001 of Dwlslon 3 of the Burr SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS
ness and Professlons Code and ms license is in full force and
effec, I .w...IN. RCB PROV10[D
6PACE3
License Number Llc Class
LIMITED TIME USE
Contractor _ Dan D.T. DA TS
1 am exempt Irom ,he lt_ensulc requucmems as I am I •ADM o
licensed arcnl,ce, or a registered professional _enclnecr saE c. Cl NO OF Insvc roR s
T7 61 TUR[
ac,mg in ms pro essnnal capactix
(Section 70Y1 BU] EX16T`1 f RLD6 ` STORIES
mess ana Dre.esslons(ode) I FINAL APP OVAL /
Llc or Reg Dato :PRESS I- USE OP BUILDING QC GDUYI / !
\� _ — �}C�
OU o'
HO`IL \ER BL,LDER DECLARATIO\ I NO De EX ISn NG BUILDINGS �OVV1 7I lVt/
ON LOT AND USE n� V�f Q O N/ L/ G'l�1�[ { Alii /'n
I herebs affirm that 1 am e.emp, train the Con ractor s —--
License Law tom he Tollowme reason iSection 7031 Bus
ness and Professions Carle l NO PA1 KING
I as owner o' the prop.rs will do the noil and th- SPACE• PMOVIDED
s,rucmrc t, no, imen&d or otfLred .or sale (SL.1101
7044 Burnes,ana Pro essluns Codes
"Pope ED use of BUILD I.
CO\STRI CCIO\ LENDING AGLNC \(
I
1 herebs affirm ,ha, here Is a constmc,lon ILndinc agencs 11 C_ IY/vL
io+ the performance of the cork lot which this permit Ic Ir
ssued (Sec 3097 CI C I
Ll
Lender s Lame —
PROPOSED MAX OCC
Lender s Address 11 667
1 certd\ that I have read this application and state that the PERM + FEE
Ibose information is Lorre C, I agree to comph w Ith a8 Counts I ISSUANCE FEE
ardiances and State laws relating to building construction
Ind herebs authorize rep-esentatwes of this Counn to enter i -OTA _FEE 5 ��
Spon the abose mentioned proven, tar Inspection purposes
"CL RC\"EASE FOR C\PLA\\TORI L.tNGhA(,E
_ Si¢hature of Permatee Date