HomeMy Public PortalAbout5818-5818 1/2TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION 76M444
CE 875(11-84) M ISCELLANEO16S APPLICATION
I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or I
a certified copy thereof(Sec.3800,Lab.Q.
fl
Policy No. Company 1, FOR APPLICANT TO FILL IN I BUILDING J f �/////��
ADDRESS („[� LV.D
Certified copy is hereby furnished. BU ILD INGr '�4� p /�/7
ADDRESS 92L . 13"-1 � C11 "fl I LOCALITY " L
Certified copy is filed with the county building inspection ! LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST „ . p^ DISTRI IxO� G CONST. / PR ESS HY
CROSS ST. 91k (�J�(� 5 (S,(
CERTIFI,C�ATE OF EXEMPTION FROM WORKERS' LEGAL ' tI
COMPENSATION INSURANCE nEscRIPT10N LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OR HLOGS.
(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
SIZE OR LOT
I certify that in the performance of the work for which this EXISTING BSMG.
� 2.. ,
permit is issued,I shall not employ any person in any manner , owNE pF&fit J'yl AI y
so as to become subject to the Workers' Compensation Laws. i MAIL OCCUPANCY GROUP o
Date Applicant ADDRESS t G - EM&KY w
NOTICE TO APPLICANT: If,after making this Certificate of CITY �L tmTE oL' 3 OCCUPANT LOAD y
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must.forth- APPLICATION FOR I EXIT HARDWARE:
with comply with such provisions or this permit shall be ' TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. E] ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 andpe' ,,,CC' C
effect. e INTI YIeS PARKING
` SPACES REq'D O PROVIDED D
License Number Lic. Class t� « L-
' LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a I FROM: TO:
licensed architect or a registered profbssional engineerSIZE OF NO.OF INSPECTOR'
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I sic wru
inessand Professions Code): i FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
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
❑ I, as owner of the property, will do the work and. the SPACES PROVIDED 5 � 1 � o�d
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF HUILDINGp(
I hereby affirm that there is a construction lending agency ', r
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
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,
and hereby authorize representatives of this County to enter TOTAL.FEE
upon the above-mentioned pro erty for inspection purposes.
' SEE REVERSE FOR EXPLANATORY LANGUAGE
I I
ignature of Permittee Date !