HomeMy Public PortalAbout5801-5803-5805TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION SE B75(2-80)
CM I5C E LLA N EO lis APPLICATION
CE 875
1 hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION t
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Polis No. Com any BUILDING
Policy p FOR APPLICANT TO FILL IN ADDRESS /
Certified copy is hereby furnished. UILDIG Na
ern LOCALITY
ADDRESS
D Certified copy is filed with the county building inspection NEAREST
department. Lo A ` d/7-
CROSS ST.
Date Applicant -----ESTDISTRICT NO. GROUP TYPE PR SED BY
CROSS ST. �`� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL •Vlor
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY >_
Ho.NO. OF BLDG (CIRCLE) STATE MAJOR SECOND CAL rL
S.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. it
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner INNER I S L I—
so as to become subject to the Workers'Compensation Laws. n OCCUPANCY GROUP V
UJ
ADDRESS CL
y
Date Applicant _
NOTICE TO APPLICANT: If, after making this Certificate of Iry ® NOTEL.
��g OCCUPANT LOAD z
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 USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl. ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. SPACES REQ'D I I PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing reyuirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSP CTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATUR
iness and Professions Code). / ,p FINAL APPROVAL
SENT USE OF BUILDING
Lic.or Reg.No. Date (/1
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that, I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- ;9 Q 8 a 1 A
ness and Professions Code): NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the # O o 0 0 8 8
structure is not intended or offered for sale (Section o 0 0 o O o o 12
7044,Business and Professions Code). oPosED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I (11 5-84
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE \
ordinances and State laws relating to building construction, TOTAL FEE Z5
and hereby authorize re sentatives of this County to enter
upon a above-menti. property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature fpermietee Date P--