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HomeMy Public PortalAbout5821TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION CE 875(11-84) fl MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a edrtified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS 7 Certified copy is hereby furnished. IdUILDI 2/ CvT [ LOCALITY ADDRENG ❑ Certified copy is filed with the county building inspection SCALITY / �+ p /� NEAR ES department. L li VST 1 CO . :sT.T Date ' ApplicantASR.EST DISTRI G O =ROCdSSED BY ��•� � CERTIFICATE OF EXEMPTION FROM WORKERS' CROS ST.LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. W/ BLOCK MAP HIGHWAY AY STATE NO. MAJOR SE CO D LOCAL I NO. OF BLOGS. (This section need not be completed if the work involved TRACT / NOW ON.LOT / (CIRCLE) USZONE SPECIAL CONDITIONS SIZE OF LOT -Z�z -7 by the permit is for one hundred dollars ($100) or less.) USE OREXISTING BLD G.I•I/� 1�*L I certify that in the performance of the work for which this c permit is issued,I shall not employ any person i �+�n any manner wrIER o as to become subject to the Workers' Compensation Laws. GOCCUPANCY GROUP / Date Applicant licant MAIL NOTICE TO APPLICANT: If, after making this Certificate of CITY 9m [cs elly TNOI. OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be ❑ ❑ No Spec. Knowl. P Y P P TRAILER USE GEOLOGY INSPECTION deemed revoked. Panic Devices ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPE CTIO I hereby affirm that I am.licensed under provisions of Chapter SAFETY PER ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code,and my license is in full force and effect. PARKING R6Q'D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE DI am exempt from the licensing requirements as I am a FROMI, T07 licensed architect or a registered professional engineer of NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. • © STORIES / SIG ATURB iness and Professions Code). RESENT USE OF BUILDING M�D, e L FINAL APPROVAL Lic.or Reg.No. Date 6/41R0J?AAC,T0,9 HOME OWNER-BUILDER DECLARATION NO. OF WXISTIN&BUILDINGS 2 8 7 4.5 A ON LOT AND USE I hereby affirm that I am exempt from the Contractor's # 0 0 0:0 8 8 License Law for the following reason (Section 7031.5, Busi 2 418 z ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). p� CONSTRUCTION LENDING AGENCY PROPOSED USE OR BUILDING MQ 'G L I hereby affirm that there is a construction lending agency 1 �,� R>�c?� © ZGE L/p/ for the performance of the work for which this permit is r issued(Sec.3097,Civ.C.). 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 building construction, and hereby authorize representatives of this County to enter TOTAL FEE , on the abo -mentioned proROAK for inspection purposes. ��C T SEE REVERSE FOR EXPLANATORY LANGUAGE % Signature of Permitt a ate