HomeMy Public PortalAbout5812-5814TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION c 875(11-s4) MISCELLANEOUS APPLICATION
11^;reby affirm'that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
m insure, or a certificate of Workers'Compensation insurance,or
a certified copy thereof(Sea 3800,Lab.Q.
J Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
l- Certified copy is hereby furnished. X BUILDINGADORE S 5814 Temple City B1Vd• LOCALITY ✓ ,
Certified
ep irfieed copy is filed with the county building inspection LOCALITY Temple City CROSS sT.
Date Applicant CNEARESTROSS ST. DiSTa•!CT p10. GROUP COp� CESSED BY
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �/J( (/J1 Of/ •fL+y/rI/(_
I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIOMWAY STATE MAJOR SECOND LOCAL
No. ICIRCLe)
NO. OF BLDGS.
(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 (S100) or less.) usE OF }
I 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 Vid &-•Shing-Chia Wang Lee
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
MAIL
ADDRESS 630 W. Huntington Dr. #228
Date Applicant rEL "J
NOTICE TO APPLICANT: If,after making this Certificate of X CITYArcadia N0.357-7028 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 No Spec. Knowl. El
deemed revoked. — —
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION>k Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ^ (LIST ITEMS BELOY.')
I 9 (commencing with Section 7000) of Division 3 of the Busi-
ness
usi — No. OF EXITS
ness and Professions Code.and my license is in full force and � /� '
effect. PARKING gE0 O I PROVIDED
� SPACES
License `umber Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FqC M: TC:
1 am exempt from the licensing requirements as I am 1
I licensed architect or a registered professional en;i:tee: slzE of INC. OF INSPECTOR'S
acting in my professional capacity See-don '051. BUS- EXISTING BLDG. STORIES _ SIGNATURE
iness and Professions Codec-
PRESENT USE OF BUILDING FIN APPROVAL
Lic.or Ree.No. Date I
I
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 0
ON LOT AND USE �i® �,(,•
1 hereby affirm that I am exempt :rout the Contractor',
I License Law for the following reason (Section '031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property. will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
1 7044,Business and Processions Code). y
g PROPOSED USE OF BUILDING Acupunture Clinic
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency
t ) for the performance of the work for which this permit is
issued(Sec.3097,Civ,C.).
Lender's Name +
PROPOSED MAXI OCC.
Lender's Address
1
25.00 I I certify that i have read this application and state that the PERMIT FEE
above information IS correct.l 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 TOTAL FEE 25,00
upon the above-mentioned property fa inspection purposes.
� SEE REVERSE FOR EXPLANATORY LANGUaFzE
14
a Si lure of Permittee Date