HomeMy Public PortalAbout5822TEMPLE CITY BLVD_Miscellaneous WO$KERS'COMPENSATION DECLARATION q
CE 875(11-84) MISCELLANEOUS APPLICATION
� CE 875
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 Insurance,e,or i ,
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING Hg QO y�� 17Y
ADDRESS U O(OC I" r
Certified copy is hereby furnished. BUILDING (�
ADDRESS _2a �• LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CRDss ST.
Date Applicant NEAREST DIST ICCC��� jjjyyyOOO GROUP TYPE 1PR 3 D BY
CROSS ST. S r n � CONST. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' I LEGAL X7 v
COMPENSATION INSURANCE I DESCRIPTION LOT NO. ,SSCP BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SSCON LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved I TRACT �6 NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) I USE OF
SIZE OF LOT 0 EXISTING BLDG. 1--
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner OWNER y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
Date Applicant RIA ADDRESS tv
NOTICE TO APPLICANT: If,after making this Certificate of CITY TNo'� )� 35 X86 OCCUPANT LOAD y
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 [J ❑ No Spec. Knowl.
deemed Ievoked. 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. ir efawe,cPARKING
SPACES R6Q'D D PROVIDED � I
License Number Lic. Class I JJ
LIMITED TIME USE
Contractor Date DATE DATE
DI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer I SIZE OF NO.OF SPECTOR'S
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES IGNATURE
iness and Professions Code). FINAL APPROVAL
'Lic.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE Z
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 ct, U
SPACES PROVIDED �[(, a
El 1, as owner of the property, will do the work and the = 11 AN a L
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING Y. I
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q. �\
Lender's Name
PROPOSED MAX.OCC.
Lender's Addr �
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 I ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter I TOTAL.FEE
upon th above- ntioned property to ' pection purposes.
ry I SEE REVERSE FOR EXPLANATORY LANGUAGE
e&Pe ittee Date
72 (�
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