HomeMy Public PortalAbout5833TEMPLE CITY BLVD_Miscellaneous (2) i
WUxhh1ZS'CUJ1YhNJA1ION ll1s(LAxA11UiV
!CE 87501.64) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self j COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or 'fl
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FI-L.L INS HUILDINCS+ 033 ✓� `G
ADDRESO
Certified copy is hereby furnished. BUILDING
ADDRESSSS �3 Z 1 LOCALITY L
ADDR
Certified copy is filed with the county building inspection LOCALITYNEAREST
department. Le CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. C�/i CONS>
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (�
WAY
COMPENSATION INSURANCE DESCRIPTION LOT NO. 13 CK MAP (CIRCLE)
STATE MAJOR SECOND LOCAL
I NO.OF OLDG
NO. ' ICIRCLE)
(This section need not be completed if the work involved TRACT NOW ON OT S. USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (S100) or less.) USE of
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this � / �—
permit is issued,I shall not employ any person in any manner OWNER � / cp LLq I`y / 1'2 n �� c
a
so as to become subject to the Workers' Compensation Laws. �-/ J OCCUPANCY GROUP c
MAIL
Date ADDRESS
Applicant LL:
NOTICE TO APPLICANT: If, after making this Certificate of elrr Q Q r(I n v NDI. OCCUPANT LOAD L
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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
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 i
effect. PARKING REO'D O PROVIDED
SPACES
License Number Lic. Class '
LIMITED TIME USE
Contractor Date DATE DATE
FROM: I TO:
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF I INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES _, SIG TORE
iness and Professions Code). '
PRESENT USE OF BUILDING
FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION ON
OF EXISTING BUILDINGS G
ON LOT AND USE
I hereby affirm that I am Tempt from the Contractor's _PE VIV`,5•
License Law for the following reason l Section 7031.5. Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
EJ I, as owner of the property. will do the work and the
structure is not intended or offered for sale (Section
7044.Business and Professions Code).
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING d 'S`f—
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
PERMIT FEE 25.00
I certify that 1 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,
and hereby authorize representatives of this County to enter TOTAL FEE 25.00
uporRhe above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
v
S, Signature of Permittee Date