HomeMy Public PortalAbout5828TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION �CE 87544(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self
insure, or a,cwtificate of workers'Compensation Insurance,or i COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u
a cdrtified copy thereof(Sec.3800,Lab.Q. I w rv' _
Poli No.-CompanyAPPLICANTBUILD IN6 xr'
Policy P � FOR /STO FILL IN pD DRESS���V J •1;'
Certified copy is hereby furnished. ADDRESS 5828 T le Cl Blvd. LO CA LIT
Certified copy is filed with the county building inspection i LOCALITYNEAREST "L
department. T le Ci cRDSs...'
Date Applicant NEAREST DISTRICT NO, OUP TYPE V CESSED BY
CROSS ST. v f! a CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF SLOGS. No. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
permit is issued,I shall not employ any person in any manner OWNER Richard Kilbas
.so as to become subject to the Workefs' Compensation Laws. MAIL pp OCCUPANCY GROUP
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ADRES3582 o
CCD
DateCitU
Applicant
TEL.
NOTICE TO APPLICANT: If,after making this Certificate of cITYTeIDple City NO. OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with .comply with such provisions oI this permit. shall be' TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ El Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Ik 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. Name of business: SPACES G RRQ'D PROVIDED
License Number Lic. Class Professional LIMITED TIME USE
Contractor Date DATE DATE
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 SIG RE
iness and Professions Code). FINAL APPROVAL .
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
office
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS _
ON LOT AND USE ,�O 7 11 t
I hereby affirm that I am exempt from the Contractor's 1 000 _001 1 Ai j :21J
139 .
License Law for the following reason (Section 7031.5, Busi-
ness
;!. i
�1
and Professions Code): NO. PARKING �/
I, as owner of the property, will do the work and the I SPACES PROVIDED
structure is not intended or offered for sale (Section .�
7044,Business and Professions Code). '•
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
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 Address
I certify that I have read this application and state that the PERMIT FEE 25.QQ
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 25.QQ
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date