HomeMy Public PortalAbout5820-5820 1/2TEMPLE CITY BLVD_Miscellaneous WORKER 'COMPENSATION DECLARATION CE 8754(11-84) M I SC E L LA N EO U S A P P L I C AT I O N
hereby affirm that I have a certificate of consent tself
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q. I '
Policy No. Company FOR APPLICANT TO FILL IN BUILDING P'7
ADORESS�
Certified copy is hereby furnished. BUILDING 917-01/y �`µP� �Lv�`
ADDRESS LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY NEAREST
department. ��y L� 6'r �O CRoss ST.
Date Applicant NEAREST ��/ ��` DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. k4r, ��fN/'f? n CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALOf
COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO.
NO. OF BLOCS. (CIRCLET
(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 07
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. c
permit is issued,I shall not employ any person in any m er OWNER AJN IvL SpA) ='
so as to become subject to the Wo ers' Compensation ws. MAILOCCUPANCY GROUP O� o
1%�iZ l�'✓ o dW�.0 W9977'
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after ing this Certificate f /N �. No�' 0/�. OCCUPANT-LOAD-
CITY D_
Exemption, you should become subject to the Workers' AP LIGATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth- '
with comply with such provisions or this permit shall be I El No Spec. Knowl.
deemed revoked. TRAILER USE GEOLOGY INSPECTION
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 and
effect. PARKING REQ'D D PROVIDED
SPACES,
License Number Lic. Class
LIMITED TIME USE
Contractor Date I DATE DATE
❑ I am exempt from the licensing requirements as I am a PROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �)C�+ STORIES / SIGNATURE
iness and Professions Code).
FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
O �f GF NO FE
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS /�
ON LOT AND USE " 1 _..
.••.••.• .•-
I hereby affirm that I am exempt from the Contractor's �1/II1�/ -,
License Law for the following reason (Section 7031.5, Busi (/ 4000-13001 2f 1/94
ness and Professions Code): No. PARKING ']�y [' [�M may.q{
SPACES PROVIDED ( 74 1 I-II 5- -
I, as 'owner of the property, will do the work and the _ _.... ...... ..._.._...__......
structure is not intended or offered for sale (Section I
7044,Business and Professions Code).
I
• CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I:
I hereby affirm that there is a construction lending agency —� fJQ.cp p.v
for the performance of the work for which this permit is
issued(Sea 3097,Civ.Q. j
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
• - _ - i
I certify that I have.read this application and state that the PERMIT FEE �
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to b ing construction, -
and herebya thorize representatives o t s County to enter TOTAL FEE t
upon the ab -mentioned p perty fo pection purposes. I
r0 z s 3 1 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Permittee Date