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HomeMy Public PortalAbout5833TEMPLE CITY BLVD_Miscellaneous I hereby affirm that I have a cert§irate )f consent 1.) ieff ..n sure. or a certificate of Workers*Compensation ImU'l-1. it COUNTY.OF LOS ANGELES BUILDING AND SAFETY DIVISION 11 a certified C00thereof(Sec. 3800.Lab'C, I Policy No.. Company COP APP!:UCANT 70 C-:L� INski ILD F7 Certified copy is hereby furnished. ALITY Certified copy is filed with the county building inzrtctlon x. �] La ary &Vbs'T'6'f'P4-_ oc 0 _ I LOCALITY �WAREST department. xx I — ROSS ST Date—Applicant L,5 14AS 7UU,4_� 4V,- . DISTRICT, ISTRicT�,tc. oZ ITYPIZ_ r74 coos sr. ';;V ;okf&-tEsSao i3y CONSILOIr. CERTIFICATE OF EXENIPTION FROM WORKER'.* LEGA COMPENSATION INSURANCE DESCRIPTION T -40. 4622 Wov LC SLOCK HIGHWAY STAT r. IdAJOR SECOND LOCAL ­,olved -R A C'r N WN 3 N _OTIusa ZONMIspr'CIAL CONDITIONS (This section need not be completed if the woric !NO. aF 91_3- by the permit is for one hundred dollars (SIOO) 13r fess.; SIDE OF *_OT USE IZE 42�0 1 EXIS?'-Fl. SLOG. h his C4 A"Aw',-Al I certify that in the performance of the work *or — permit is issued. 1 shall not employ any person in any so as to become subjJecz to the Workzers* Can, Ow— of building A M ILA e- 7-/--A/ IL ::CC'_'PANCV 280up S V/Date '�'D Applicant ADOR Ess W NOTICE TO APPLICANT: If. is Tv Exemption. you should become subject to The 'A 1-gars' _Te7A1e___ -=UPAN 7 OAD Compensation provisions of the Labor Code. ym- =1 Z -onnn- with comply with such provisions or -itis -wrmi: u-';1 :e deemed re;!OKed, JSE I Ne Spec. Knowl, LICENSED CON-1`R.-%CT ORS DECI-0. ATTOI, OCCUPAXCv Pnric Devxes I hereby affirm -,ha* I am Hcerised 9 (commencing W -,. idi 5e%.-,.on -000) of Division :SAFE-- -MR-417 ME:-O,..; ness and Professions C,.da. and my 'iczanse 's -.-ij NO. _. ek1Is effect. `XXX iliarne o.-E business P- v License Number 45-<We'. T.A4 1 ;ZED L1'j'VjjT1:D TINK: USE Contractor- Dart z_7. DArm I am exemot from the licensing :eq*airem.!­.• ..n' licensed arc% hitec: ora 7P C ' acting in :ngprofessioq_-I'.apa.--'-.y Se�-;Vj. SLZG. iNSPE T CR3 mess and P-ofess4ons Code I. SIGNA-URS .1-iNAt APPROVAL 7N Sul. Lic.or Re=.No. HOME OWNER-31 ILDEI D1E('LAR.A:':,: I hereby affirm :hat I am exempt from License Law for the following reasonSe.:ion ness and Professions Code I: •I'AC. P 4RKING 0 1, as owner of :he orooerzv. will !a :I:: SPACES -qOv:OE:) structure is not inandea ar xiened for ia:e 70-14.Business and Professiors C,Elai. CONSTRUCTION LENDING.-XGEN( ,' PROPOSED 'J3E: OF MU:L=I.IIG I hereby affirm that there is -, consz"'Licton Ien'd;­ ...I... for the performance of the work for :thick issued(See. 309-.Civ.C.). Lender's Name Lender'sAddress PROPOSED MAX. OCC. I certify that I have read this application and state -::az :he PE.RNII-FEE 95,001 above information is correct.I agree o comvl%*wit!, ISSUANCE FEE ordinances and State laws relaiirg to build-in and hereby authorize representatives of this Court:- enter TOTAL FEE ! upon the above-mentioned property for inspec-.ionp...*':P)ies. 25.'00 xxii xx -7-r-&I SEE REVERSE FOR EXPLANATORYLANGL7.kGE Y SigtAatur'e of Perni-Iiiee Da-,.-,