HomeMy Public PortalAbout5811-5811 1/2-5813TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUEl ILDING
ADDRESS
Certified copy is hereby furnished. AcuREss LOCALITY
❑ Certified copy is filed with the county building inspection ocALITv Gf
NEAREST
department. l �5_ CROSS ST.
Date Applicant AREST DISTRICT NO. GROUP TYPE P SED Be
GROSS ST. �j^ CON
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIG Nw AY STATE MAJOR SECOND LOCAL
NO,���J}.�� (CIRCLE)
NO. OF BLOCS. ••/"
(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 ($100) or less.) usE OF
S ZE OF LOT EXISTING BLDG. �"•
I certify that in the performance of the work for which this _ o
permit is issued, I shall not employ any person in any manner OWNER >
5o as to become subject to the Workers' Compensation Laws. AIL ` OCCUPANCY GROUP o
~•
Date IV AD RES Applicant _
NOTICE TO APPLICANT: If, after making this Certificate of , ITY� TEL.
OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLI ATION FOR EXIT HARDWARE:
with comply with such provisions oI 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 PERM ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKINGR9Q'D D PROVIDED D
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I ATURE
iness and Professions Code).
FINAL APPROVAL �/jjfr72 /
PRESENT USE OF BUILDING �J
Lic.or Reg.No. Date !
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE ,
I hereby affirm that I am exempt from the Contractor's I
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
DI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code). ` Z
PROPOSED USE OF BUILDING � 3 1111 A
CONSTRUCTION LENDING AGENCY 1f # o o 0 o
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 0 0 0 0 0 0 o z
issued(Sec. 3097,Civ.Q.
Lender's Name b � 06236-87
PROPOSED MAX. OCG.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE ,
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize reFj!
of this County to enter i TOTAL FEE 95
n the b t' dr i ection purposes.
ZZ— SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per Date i
I