HomeMy Public PortalAbout5821TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION 76M444
ICE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or•a certificate of Workers'Compensation Insurancc e,or I �
a certified copy thereo (Sec.3800,Lab.Q. q -
Policy No.l'�4 (Sec.
TI'G',..lF! 41.P.�'7 �� FOR APPLICANT TO FILL IN BUILDINGiia/
ADDRESS d0
Certified copy is hereby furnished. B ILDING S, r I vc LOCALITY
ADDRESS
77
Certified
p rtie ecopy is filed with the county building inspection ALITY 2 (� r I C ceoss sr.
Date Applicant NEAREST DISTRICT NO. G OUP TYPE P ESSED HY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL pe
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OR SLOGS.
(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 EXISTING BLDG. �-
I certify that in the performance of the work for which this e
permit is issued,I shall not employ any person In any manner OWNER rr� i s�
so as to become subject to the Workers.' Compensation--.... MAIL / / OCCUPANCY GROUP
ADDRESS / O [I L I ( Z—e t5_Date Applicant TE
NOTICE TO APPLICANT: If, after making this Certificate of CITY �„ .r [ .o /(v� No 8 r8 Z���Z(� OCCUPANT LOAD a
Exemption, you should become subject to the Workers' z
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 INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST Prams 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 SPACES RSQ'D O PROVIDEDGor
D
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE GATE
ElI am exempt from the licensing requirements as I am a RROMI TO!
licensed architect or a registered professional engineerSIZE OF NO. OR INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL /`/�_
Lic.or Reg.No. Date PRESENT USE OF H ILDING [O [
G �. 0
151 O�-
HOME OWNER-BUILDER DECLARATION NO, OF E STING BUILDINGS GJ NO EEE
ON LOT AND USE �(i J
I hereby affirm that I am exempt from the Contractor's �19'
License Law for the following reason (Section 7031.5, Busi- b l 0000-0001 5/ 3/93
ness and Professions Code): NO. PARKING —/
I, as owner of the property, will do the work and the SPACES PROVIDED 9507 1 AM 9;313
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency a. ej
for the performance of the work for which this permit .is e
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC. `
Lender's Address 1r
PERMIT FEE n
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
on the above-menti d property for inspection poses. iSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 'Datef