HomeMy Public PortalAbout5835TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION CE 876(7 1-84) MISCELLANEOUS A P P L I C A T I O N
I hereby affirm that I have a dertimpof consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
AD OR ESS
Certified copy is hereby furnished. BUILDING - LOCALITY�tvt �•
j,
ADDRESS � G
Certified copy is filed with the county building inspection LOCALITYNEAREST
department. Q' 1 e ESS ST. Lle, 11
Date Applicant NEAREST DISTRICT NO. GROUP TYPE RO ESSED BY
ceoss sr. ,3J KAi U�j colvsr.�/ ti
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND L AL
NO. (CIRCLE)
NO. OF BLDGS.
(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. CD
permit is issued, I shall not employ any person in any manner +A131)RrESS
WNER — �� U
so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP o
3 -02votble e
Date Applicant I„
NOTICE TO APPLICANT: If,after making this Certificate of CITY ,Q- t N.- �1� 0 OCCUPANT LOAD y
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLI ATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. ❑ Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
E]
hereby affirm that I am licensed under provisions of Chapter SAF TY 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. PARKING
SPACES REQ'D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date r DAT 6 DA TQ
I am exempt from the licensing requirements as I am a FROM. TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES IGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
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 =
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 Q
above information is correct.I agree to comply with all County ISSUANCE FEE 0.
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioned prop ty fpr inspection purposes.
1 \ rr SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee hate