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-,.-,