HomeMy Public PortalAbout5827-5827 1/2-5729TEMPLE CITY BLVD_Miscellaneous (2) I WORKERS'COMPENSATION DE(*'L.\RAT1pN a
CE 875 •1 t•84) MISCELLANEOUS APPLICATION
CE 87
1 hereby affirm that i have a certificate of consent to self
insure. or a certificate ol'Workers'Compensation Insurance.air COUNTY OF LOS .ANGELES BUILDINGAND SAFETY DIVISION
a certified copy thereof•(Sec.3800.Lab.C.I. r
Poiicy No, -C omnam• FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. Bu1LDESS
IN /d J
AD DR
G 8Z �M `G / �(i LOCALITY
I 1 El
Certified cr+py Is filet!with the countx buildlne inspection LOCALITY
department. Temple City DEAREST
CROSS ST.
Date Avrllicant NEARESTDIST T N GRQ�P TYPE CESSED BY
CR055 ST. &&., e, �� /�'¶ CON
CERTirlC ATE OF EXEMPTiON FROM'VORKERS' LEGAL �I
l O�IPE`5.1T1gN INSI'R 1Nl'IG DE SCRIPT:O+I LOT NO. BLOCK 1+ipy w,c ww wY
yo (CIP CL=I STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need nor he comaleted if the \lark Involved l�gAC� NOI,' ON LOT USE :ONE 3PE CIAL CONDITIONS
by the permit is for one hundred dollars +51001 or less.)
t 15ICE OF LOT I USE OF
I certify that In the verf,n dance o -he ;A:-hick -.his EXISTING BLD,_
permit is issued. I ,hall not emplm anv 'Ie7ion :n am manner XI OWNER ���/}
so as to )+ecome 4tibiect :o the 1• orkel 1-oni-ensatio!t !..)\l G. MAIL O 6� k OCCUPANC'• 3ROL'P I I -
Date Applicant ADDR_ss S8l4 Ttg . te[� (7 V
NOTICE TO APPLICANT- if.wf-er makim_ :his - . uicare ',r ?$i C:T• s/e�i fio vc ��� Z8d?'7/0 OCCUPAN- LO+C
Exemptio-t. you should hecom :uhiecr 70 -}ru It •rl er,'
Compensation ern is)ons ti;hc Labor-.'.,de. you mt:si torch_ I V -NPDL!CA'IC'\' =?G -
I with cont^iv %%ill: .uch r•rovi,hinq - iii. ^er:nil ;hail he I
'\ deemed retnKea. -RAILER :USE GEOLO.Y 'NFPz',:T:CN _ No Srec. K',c'v1,
z LICENSEDCON1RACTORSDECLARATION DCCuPANCY IN5PECTIONf= Pan;cDev;ces
_ I !lereb} affirm.iim :lt:tt I am licensed aide:arc\iciOr.S o:Citavter SAFETY PERMIT - !LIST ITEMS BELOW)- " 9 tcommencine with Semion -000) of Division )i the Buri - No. of EXPr5
ness and P-ofe:sionq Code.and my license is in full frrce and
eiiect. -'ARK INGPROVIDED
n SPACES REO•D
License Numbe-_. — I_i.. C!a:, loo
LIMITED TIME USE
y Date t
y __-__ .tti __._ DATE DATE
W
V. I am e%empt trout .Ice :icensine reauiremeniq as I :,.in .I TO:
I licensed ar1_hi1CC: Or a :e4_tstered rrnfessional eneincer 3IzE Or NO. Dv INsPE TORS
z actin. :n n} rrofc::ioral rl is --.. i, -": Iii::• EXISTIv; BLDG. --JP.r� s1G LI
REE
IlteSi an !'rI1lCutt n,l odel. FINAL APPR IAL— _—�—
tj oq ESEN- USE OF BUILDING
i
- I
140NIE OX►Ni'R-BUILDER DECL.Mi.moN NO. OF EXISTING BUILDINGS
• NV
ON LOT AND USE \ 4 840 ICO FEE EE
I hereby affirm 'hat I am cacmpt from the Contractors V V -
License Law for the followin__• reason 'Section -'I:1.:. Bttci i 1 � 1-[ji i0 11 1 �, a
ness and Professions Cade): NO. PARKING
1, as owner of the property. will do fife work and the SPACES PROVIDED
structure is not intended or offered int :ale (Section
1 7044.liusine<s anti Professions Codel.
CONSTRICTION LENDING AGENCY PROPOSED USE OF BUILDING
1 IICTeby affirm that there is a construction lendinemcncv '
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
i I certify that 1 have read this application anti state that the PERMIT FEE 25,00
above information is correct. I aerce 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 25.00
r I upon the abov entione property r inspection purposes.
I /�� / r� SEE REVERSE FOR EXPLANATORY LANGU 1GE
I 2 � � 2 " l '��v I
Sienature of Permittee Date