HomeMy Public PortalAbout5811-5811 1/2-5813TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION 176M444CE 875(2-80) MISCELLANEOU6 APPLICATION
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I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BI�I
ADILOING
DRESS ''�
❑ Certified copy is hereby furnished. BUILDING I
ADDRESS LdCALITY
❑ Certified copy is filed with the county building inspection01 /� NEAREST G•
department. LO CALITYTemple City CROSS ST.
Date ApplicantEARESDISTRICT No. GROUP TYPE PROC SSED BY
to CROSS -TT- Workman er 'r _ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALFz
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
(CIRCLE)
STATE MAJOR SECOND LOCAL
NO. OF BLDGS. No. t-
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.) USE OF U
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 Chiman Lad
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP CJ
W
Date Applicant
ADoREss5813 Te le 'ty Blvd,
NTEL
NOTICE TO APPLICANT: If, after making this Certificate of clTv No- _ OCCUPANT LOAD ?_
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 N $ ❑
deemed revoked. ❑ O Spec. KnOWi. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION04
Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW)
%(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, PARKING
SPACES
REO'D E= PROVIDED O
Ilcense Number Lic.Class
LIMITED TIME USE
Contractor Date j DATE DATE
F1FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
Vacant
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-
ness and Professions Code): NO. PARKING
❑ F i, as owner of the property, will do the work and the SPACES PROVIDED 7 A I � ,
structure is not intended or offered for sale (Section
1
7044,Business and Professions Code). oo o o o 8PoseD USE OF BUILDING ,
i
CONSTRUCTION LENDING AGENCY I c o 0 0 0 0 o N
I hereby affirm that there is a construction lending agency Design office
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
ordinary re th and State laws relating to building construction, TOTAL FEE
and tJ rpresentatives of this County to enter
upo thea e- d property f ection purposes. EE REVERSE FOR EXPLANATORY LANGUAGE
s 4 D,
Sig a ure o erm t !/ Date Q j
I