HomeMy Public PortalAbout5828TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION I
CE 875(11-84) MISCELLANEOUS APPLICATION
•'' � CE 875
I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES 'BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. CompanyFOR APPLICANT TO FILL IN ABUILDING
DDRESS
Certified copy is hereby furnished. 013UILDING
ADDRESS LOCALITY
Certified copy is filed with the county building inspection LO AI.ITY NEAREST
department. CROSS ST.
Date Applicant EAREST DISTRI�'jVO. GROU TYPE RROCE ED BY
CROSS ST. /�/ CONS'P:j,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V6,/O J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR S OND LOCAL
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ONOF LOT S. USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. ,
I certify that in the performance of the work for which thisI C:)permit is issued,I shall not employ any person in any manner OWNER d /�j ,�,C. ''
so as to become subject to the Workers' Compensation Laws. f / �/{�/l//� •OCCUPP.AN.CY•GR04JP\•,' � �
'MAIL
V VDRES
ADRESS / IE- iVb V Ci ,` ' ' •' '' ,`'• C~3
Date Applicant ; us
TEL OCCUPANT LOAD n'
NOTICE TO APPLICANT: If, after making this Certificate of CITY ��jky �y � No. Q56,6
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 oI this permit shall be TRAILER USEGEOLOGY INSPECTION E]deemed revoked. E] ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTio Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PER T ❑ (LIST ITEMS BELOw)
9 (commencing with Section 70009 of Division 3 of the Busi I NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING
SPACES
REq�D D PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM: TOI /
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTORS
acting In my professional capacity (Section 7051, Bus- E STING BLDG. STORIES SIGNATURE
iness and Professions Code).
EEFINAL APPROVAL
PRSNT USE OF BUILDING
Lie.or Reg.No. Date /� /
c,, • ,& 4
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-
ness and Professions Code): NO. PARKING O.1 OI 9 A
❑ I, as owner of the property, will do the work and the SPACES PROVIDED # 0 a 0.0 8'8
structure is not intended or offered for sale (Section 0 In
7044,Business and Professions Code). o Io 0 0 0 ,0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING i)
7, 1 4 88
I hereby affirm that there is a construction lending.agencyC . I r G � !GA,
for the performance of the work for which this permit is �►► ��7?
issued(Sec.3097,Civ.Q. C
Lender's Name
i PROPOSED MAX. OCC.
Lender's Address p
PERMIT FEE J '
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, Q /
and hereby authorize representatives of this County to enter TOTAL.FEE
upon the above-mentioned prope y for inspection purposes.e 0a SEE REVERSE IrOR EXPLANATORY LANGUAGE
�iggaitu.^.fittee Date