HomeMy Public PortalAbout5837-5839TEMPLE CITY BLVD_Miscellaneous `WORKERS'CObiPL'NSATION DECLARATION CE 875(11-84) M I SC E LL.A N - 0 SAI 1 L I C AT I O N
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BLFILDING AND SAFETY DIVISION
insure, or a cerrificat�of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Com apy �� BUILDING&Z5
�'tl�i/ FOR APPLICANT TO FILL IN ADDRESS D G
Certified copy ispely rnished. BUILDINGADDRESS /� �, , mLOCALITY
Certified copy is pith the county building inspection LOCALITY ��, � ARII NEAREST
department. ¢j�, �%t'I 6 V/1 CR OSS ST.
Date Applicant NEAREST RICT NO. GtJOUP TYPE P CESSED BY
CROSS ST. J(f`�� J�� _y CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. �' BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLOGS.
(This section need not be completed if the work Involved TRACT D NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) US
OF
SIZE OF LOTEXISTJNCI BLD G.PW a
I certify that in the performance of the work for which this o
permit is issued, I shall no employ any person in any manner OWNER i o'-'JO if17A40 ='
so as to become subject t rerkers' Compensation Laws. OCCUPANCY GROUP
MAIL Date A ADDRESS i� �aNOTICE TO APPLIC If TE
r making this Certificate of clrY 3 No� OCCUPANT LOAD
Exemption, you sho Id
become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forthIf-
with comply with such provisions oI 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 PERMI ❑ (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 /� L� n /1 C
effect. t Q T ? I f ?S I PARKING REq'D PROVIDED
License Number A Lic. Class 1W.
SPACES
1�tLIMITED TIME USE
ContractorDate DATE DATE
❑ 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 sI TORE
iness and Professions Code). FINAL APPROVAL ` �✓i j
! 77/
Lic.or Reg.No. Date PRESENT USE OF BUILDING G
HOME OWNER-BUILDER DECLARATION No. of EXIST BUILDINGS 0 ��
ON LOT AND USE ^ I n
I he by affirm that I am exempt from the Contractor's .I_. r.,
Lic se Law for the following reason (Section 7031.5, Busi- rod /' I�I�:�L I_uli1 :I/ ,x/713
Itstructure
and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED ?506 1 Art 9:29
is not intended or offered for sale (Section
7044,Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 6
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. OCG.
Lender's Address
I certify that I have read this pplication and state that the PERMIT FEE
above inforrnaU1013,is correct.I agree to comply with all County ISSUANCE FEE
ordinances a tate laws relating to building construction,
and hereb thorize representatives of this County to enter TOTAL FEE A
upont' ned ro inspection pur oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ermittee to