HomeMy Public PortalAbout5820-5820 1/2TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION I 76M444
CE 875(2-80) MISCELLANEO I S APPLICATION -
' I hereby affirm that I have a certificate of consent tP self .COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.-C.)
Policy No�Company FOR APPLICANT TO FILL IN BUILDING p^)� t Z
' ADDRESS O of
❑ Certified copy is hereby furnished. I pDDRE53 LOCALITY �� C
Certified copy is filed w h the county buil g inspectio NEAREST
depa men + LOCALITY ceoss sr.
I CA TIM
Date G pplica EAREST DISTRICT NO. G TYPE / PROC SEN BY
CROSS ST. S ,(� ►^} CONST.
C RTI ICATE OF MPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT Nd. BLOCK MAP a DO-� HIGHWAY
_ / ( ) STATE MAJOR SECOND LOCAL a
No: OF SLOGS.
(This section need not be completed if the work invplved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q
by the permit is for one'hundred dollars ($100) or less.) USE OF V
SIZE OF LOT EXISTING BLD C•
I certify that in the performance of the work for which this
04;
permit it issued, I shall not employ any person in any manner OWNER 0
so as to become subject to the Workers' pensation Laws. OCCUPANCY GROUP �''Z W
MAIL
Date Applicant woDRESs co Logc 1 CL
rEL. OCCUPANT LOAD 2
NOTICE TO APPLICANT: If, after ma trig this Certificate of CIT NO.
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with Such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. ❑
deemed revoked. ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION11
Panic Devices
I hereby affirm that I am.licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS a
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, my license is in f forcC'and PARKING.
effect. REQ'D o PROVIDED
SPACES
License Number Lic.Class
LIMITED TIME USE
Contractor Date I DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I m a
licensed architect or a registered professiotial engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Rek.No. Date
r
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
N LOT AND USE
I hereby affirm that,I am exempt from the ContraO
ctor's _
License Law for the following reason (Section 7031.5, Busi-
ness and Profdssions Code): I NO. PARKING
SPACES PROVIDED
I, as owner of the property, will do the work andjthe
structure is not intended or offered for sale (Section / C '
7044,Business and Professions Code). PROPOSED USE OF BUILDING zq 2 6 Jr,2 A
CONSTRUCTION LENDING AGENCY / #'o D 0,'o 8 8
I hereby affirm that there is a construction lending age cy Ili O'Ff�
for the performance of the work for which this permi is o o a o D D 0-IR
issued(Sec.3097,Civ.C.).
Lender's Name PROPOSED MAY:;. OCC. 1, 5L$2
Lender's'Address I PERMIT FEE. b
I certify that I have read this application and state that Ithe
I
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws' ating to building constructii1 1 TOTAL FEE D
and hereby authorize repre a tatives of this County to enter rQ
upo the,above-mentioned roperty•for inspection urpos SEE REVERSE FOR EXPLANATORY LANGUAGE
14I
ature of Permittee V Date