HomeMy Public PortalAbout5835TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS
����A & �R1R�®�� ��®�IrA�I®A1 `
CE 875(2-80) L L� Y�l APPLICATION
I�I
I hereby affirm that I have a certificate of consent to self COUNTY OF ]LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or � k
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS 5IF Ai
❑ Certified copy is hereby furnished. BUILDING 13JAD LOCALITY T�G-
❑ ADDRESS Lam/ �D✓Ya�
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date Applicant NEAREST DISTRICT NO. [(,ErRO'UP TYPE IPROCIESSEM13
CROSS ST. '�TN
AcS `*.� D r/ CONSS�.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v f a
COMPENSATION INSURANCE DESCRIPTION BLOCK MAPr� HIGHWAY STATE MAJOR SECOND LOCAL >_
(CIRCLE) a
NO. OF BLDGS. NO. c;1oC
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) or less.) V
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 Wxrn9*v"moLur1'*-m
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPDRESS E�E�] W
Date Applicant 700 ,� W' s W
AD
NOTICE TO APPLICANT: If, after making this Certificate of clry Hy .a NoL lit�~ Ira OCCUPANT LOAD
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 NOS pec. KnOWI. ❑
deemed revoked. P
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. �
License Number SPACES REQ'D PROVIDED Lic.Class 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 SIGNATURE
iness and Professions Code). +— PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
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
� SPACES PROVIDED
❑ I, as owner of the property, will do the work and the #� o D o 0 8 PC
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PRoroseD USE of BUILDING o o D o o D D Q'
CONSTRUCTION LENDING AGENCY i 0,06-81
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.C.).
Lender's Name PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
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, TOTAL FEE
and hereby authorize representatives of this County to enter
upon the above-m ntioned pgpert for inspect'on Purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dale