HomeMy Public PortalAbout5801-5803-5805TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION 176M444 M I SC E L LA N E O U APPLICATION
I luaffirm that I have certificate of consent tself 'CE 875(11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insurere,, o or a'certificate of Workers'rs'Compensation Insurance,e,or
` a certified copy thereof(Sec.3800,Lab.Q.
Policy No.—Company
FOR APPLICANT I`O FILLrJN BUILDING D
ADDRESS
Cert'fed copy is hereby fur ed. BUILDING ��[ d� �/,C �F ` LD CALITY
\may ADDRESS a Dv ` �J
fCe fed copy is filed with ih county building inspection LOCALITY NEAREST
I mgnt. Temple City CROSS ST.
Date V Applicant NEAREST A, JISTR ICT NO. GROUP TYPE CESSED BY
CROSS ST. �� —Nola S 1 ,O fj CONnz
I CE TIFICATE OF EXEMP 1 FROiti WORKERS' _ — L, `dam
COMPENSATION INSURANCE I DESCRIPTION LOT NO. HLO CK NA. HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIN CLE)
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars 6100) or less.) USE OF
1 SIZE OF LOT EXISTING BLDG. •"
I certify that in the performance of the work for which this _
permit is issued.I shall not employ any person in any manner OWNER '� 4 'E L4J G L-z
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUPIZI
=
MAIL IGi / flu_I T/�i�tprA Iti
ADDRESS -11
Date Applicant
NOTICE TO APPLICANT: If,after making this Certificate of X CITY `��� NO. Z�- OCCUPANT LOAD
Exemption. you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
provisions of the Labor Code,you must forth-
) with comply with such provisions or this permit shall be TRAILER USE 0 GEOLOGY INSPECTIONNo Spec. Knowl.
❑
deemed revoked. 1 —
f LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION$$ Panic Devices
I hereby affirm that I am licensed under provisions ofC apter SAFETY PERMIT (LIST ITEM BELOW)
I 9 (commencing with Section 7000) of Division 3 oftYe Busi- j NO.OF EXITS
i ness and Professions Code,and my license is in f force and
effect. I SPACP�RKS REQ'O PROVIDED
SPACES
o License Number Lia Cl i
LIMITED TIME USE
LL 1
N Contractor Da I DATE DATE
Z 1 iii
I am exempt from the lic sing requirements as I am a PdDM: TO:
m f I licensed architect or a gistered professional engineer I SIZE OF NO. OF INSPE R s
Z I acting in my professio al capacity (Section 7051, Bus EXISTING BLDG. STORIES SIG E
m iness and Processions de).
FINAL APPROVAL
0 PRESENT USE OF BUILDING
L) Lic.or Reg.No. Date I ► /
is f i _ I
i
HOME 01 R-BUILDER DECLARATION NO. OF EXISTING BUIL Ncs ��
ON LOT AND USE
I Hereby affirm t I am exempt from fife Contractor's
i f I License Law fo the following reason (Section 7031.5, Busi- , }
1 nese and Profe ions Code): ' NO. PARKING
SPACES PROVID D
I, as o�v er of the property, will da the work and the t
structur is not intended or offered for sale (Section j
f 7044, siness and Professions Code).
PROPOSE USE OF BUILDING C ' '
ONSTRUCTION LENDING AGENCY
I Hereby affirm that there is a construction lending agency
( f for the performance of the work for which this permit is
issued(Sea 3097,Civ.Q. i
Lender's Name i
PROPOSED MAX. OCC.
Lender's Address t I
I certify that I have read this application and state that the i PERMIT FEE 25.00
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter I TOTAL FEE 25.00
upon the above-mentioned property for inspection purposes.
' SEE REVERSE FOR EXPLANATORY LANGUAGE j
Signature of Permittee Date
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