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HomeMy Public PortalAbout5818-5818 1/2TEMPLE CITY BLVD_Miscellaneous (2) Ir; ! ! 'ERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N k O U S APPLICATION CE 875 affirm that I have a certificate of consent to c self !! COUNTY OF LOS ANGELES I�. BUILDING AND SAFETY DIVISION a certificate of Workers'Compensation Insurance,or I , I copy thereof(Sec.3800,Lab.C.). _ :o. Company FOR APPLICANT TO FILL IN BUILDING �J ADDRESS / _ Certified copy is hereby furnished. BUILDING ll LOCALITY ADDRESS / �y Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. ate Applicant NEAREST DISTRICT NO. tdlioup TYPE PROCESSED BY .CROSS ST. I1�Lwr a ff/� 0f CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I� —�' COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY CIRCLE) STATE MAJOR SECOND LOCAL NO. ( (This SBCtIOn need not be completed if the work involved TRACT NO. OF BLDGS.NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. I permit is issued,I shall not employ any person in aAy manner OWNER 0 ( p�(/ Kt.. ^ ! s� so as to become subject to the Workers�Compensation Laws. MAIL i OCCUPANCY GROUP o Date Apphcan ADDRESS yt C TEL OCCUPANT LOAD NOTICE TO APPLIC1A�If, after makin his Certificate of CITY Le� No. I y 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 ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMW[]% (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 fn full force and effect. PARKING R6Q'D D PROVIDED CO ' SPACES License Number Lic. Class LIMITED TIME USE Contractor Date I DATE DATE I am exempt from the licensing requirements as I am a FROM: TOI licensed architect of a registered professional engineer ' SIZE OF' NO. OF INSPECTOR'S acting m my' professional capacity (Section 7051, BUS' EXISTING BLDG. STORIES SI ATURE iness and Professions Code). /^y` FINAL APPROVAL I� PRESENT USE CF BUILDING Lic.or Reg.No. Date I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING UILDINGS 1 ON LOT AND USIV 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 FIE structure is not intended or offered for sale (Section 7044,Business and Professions Code). 1 �J ,._ CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ! I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is "*jr CY issued(Sec.3097,Civ.Q. Lender's NameAM#f;c r PROPOSED MAX. OCC. ' Lender's Address I , I t V `^ �1 p I I certify that I have read this application and state that the PERMIT Fee � l above information is correct.I agree t coinply with all County ISSUANCE FEE CA ordinances and State laws relati o building construction, , and hereby ize representat' es of this County to enter TOTAL. FEE, I the - lent' d y..for'nspection pu oses. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Per;iitte Nite ',