HomeMy Public PortalAbout5827-5827 1/2-5729TEMPLE CITY BLVD_Miscellaneous WA RKERS'COMPENSATION DECLARATION :16M444
CE 875 (2-80) MISCELLANEOUS ,APPLICATION
I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insfre, or a certificate of Workers'Compensation Insurance,or ,
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDIN
ADDRESS `7
G �+SA 112-
❑ r
Certified copy is hereby furnished. BUILDING I (� LOCALITY
ADDRESS ivAl
ElCertifiedcopy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date Applicant AREST �� DISTRICT NO. GRO}}}111P TYPE PR SED BY
CROSS ST. ,/ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' I LEGAL V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. 2D07 (CIRCLE) STATE MAJOR SECOND CAL tl
NO. OF BLDGS. Q
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS IJ
by the permit is for one hundred dollars ($100) or less.) U
USE OF-
SIZE OF LOT EXISTING BLDG. l (r
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner WNER C U
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP W
ADDRESS IL
Date Applicant
NOTICE TO APPLICANT: If, lifter making this Certificate of CITY `G oL. 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 TRAILER USE❑ GEOLOGY INSPECTION NO Spec. Knowl. ❑
deemed revoked. ( Panic DBVIC@S ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect' SPACES REWD E=:= PROVIDED D
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ I FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I NATUR
iness and Professions Code). P SENT USE OF BUILDING . FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- 2 0 9 3.4 A
ness and Professions Code): NO. PARKING
SPACES PROVIDED # 0 0 0 0 8
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section o 0 0 0 0 0 0
7044,Business and Professions Code). ROPOSED USE OF BUILDING I 0, 19-84`OV 4
CONSTRUCTION LENDING AGENCY lJ q 1 79
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.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
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, TOTAL FEE
and hereby authorize representatives of this County to enter
upon the above-mentioned property inspe ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Datfi
1 I