HomeMy Public PortalAbout5812-5814TEMPLE CITY BLVD_Miscellaneous �WOR.KERS'COMPENSATION DECLARATION CE 876(2-80) I SC E L LA.N E®,lJ S A PP L' ICAT
I hereby affirm that I have a certificate of consent to self ' COUNTY OF LOS ANGELES I BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or i
a ori tihed copy thereof(Sec.3800,•Lab.C.) I t,
Policy No.._: Company. FOR APPLICANT TO FILL IN ), ADDRESS
❑ 'Certified copy is hereby furnished. org UILDI.NG 5�1 1 LOCALITY
❑ ADDRESS I
Certified copy is filed with the county building inspection NEAREST
department. L CALITYMe 7k /` iI CROSS ST,
Date Applicant 60 NEAREST ( DISTRICT N [A.OUP TYPE PR SEED BY
CROSS ST. J � �� CONST.
CERTIFICATE,OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE NO.DESCRIP710N LOT NO. BLOCK �, MAP .(CHIGHWAY TR CLE) `
STATE MAJOR SECON CAL r
I
NO. OF BLDGS. Q
(This section need .not be completed if the WOIk involved. TRACT NOW ON LOT ` USE ZONE SPECIAL CONDITIONS
' by the permit is for one hundred dollars ($t00) or less.)I USE OF
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 kto A,• N O
so-:as to become.subject to the Workers'Compensation Laws. AIL OCCUPANCY GROUP k��]
U
)� �j' f LU
Date . Applicant. ° ;eR t . EL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY' 1 NO. 1 j� s-�� Z i OCCUPANT LOAD z.
Exemption, you should become subject to the Workers' ', ��� FOR EXIT HARDWARE:.,
Compensation provisions of the Labor Code, you must forth 'APPLICATIONI'
with comply with such provisions or this permit Shall be TRAILER-USE GEOLOGY INSPECTION I "
deemed.revoked. ❑ ❑ ! No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION _
Panic Devices ❑
I hereby affirm that I am.lidensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) ,� NO..OF EXITS
9 (commencing'with Section 7000)of Division 3 of the Busi- ;
ness aild Professions Code, and my license is in full force and. PARKING.
effect: I' • REQ'D PROVIDED
SPACES
License Number,.'. Lic.Class .
LIMITED TIME- USE
Contractor Date I' DATE DATE
.❑ .. . , , 1 FROM: - r TO:
I am,exempt'from. the licensing requirements as. I am.a:..
licensed. architect Or'a registered professional engineer' SIZE OF -NO. OF INSPECTOR'S
acting in my professional capacity.(Section 7051, Bus- EXISTING BLDG. STORIES f SIGNATURE
iness and'Professions Code). r J� C ; FINAL APPROVAL
ESENT USE OF BUILDING, 2 .14, _
Lic.or'Reg.No. Date
HOME OWNER-BUILDER DECLARATION. NO.OF EXISTING BUILDIkr3S,-_
.ON LOT AND USE
I hereby affirm that,I .am exempt from the Contractor's ti
License Law for the following reason (Section 7031.5, Busi•'
ness and Professions Code): NO. PARKING. I' A 12 3,7 A
SPACES PROVIDED I ,
❑ I,,as owner of the property, will do the work and the ! # o 0 0 088
structure is not intended or offered for sale (Section + 0.0 o-o O o o
7044,Business and Professions Code). OPOSEO USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is I
issued(Sec.3097,Civ.C.). f
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
and hereby authorize representatives of this County to enter
upo�i th[e abb e-mentioned property for Inspp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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