HomeMy Public PortalAbout5837-5839TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self
insurer, or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS ���
Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS T /n '� C
FlCertified copy is filed with the county building inspectionLOCALITY —r6m '1 �~ NEAREST
department. CROSS ST. 1
Date Applicant NEAREST DISTRICT GROUP-
TYPE PR SSED BY
CROSS ST. 7— CONS
5',U
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SE OND LOCAL
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
SIZE OF LOT EXISTING BLDG. a
I certify that in the performance of the work for which this ,Q ,,� CD
permit is issued,1 shall not employ any person in any manner OWNER /_, /U A 1 ,- � i4 �'e J•V
so as to become subject to the Workers' Compensation Laws. MAIL � OCCUPANCY GROUP D=
V Pn�i ST-
Datelk
ADDRESS `
Applicant
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of CITY S u_ �(. /►)O/l-,Tr o. — z
Exemption, you should become subject to the Workers' C _
Compensation provisions of the Labor Code,you must forth APPLICATION FOR EXIT HARDWARE:
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
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
effect. PARKING
SPACES REQ D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TOI
licensed architect or a registered professional engineer SIZE OF NO. OF .MrRI
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
/� �
) FINAL APPROVAL °
Lic.or Reg.No. Date PRESENT USE OF BUILDING IV
0 0 o a
60
HOME OWNER-BUILDER DECLARATION NO, of EXISTING BUILDINGS
ON LOT AND USE 1217-86
b
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
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code). '
PROPOSED USE OF BUILD �"
ING • C (v
CONSTRUCTION LENDING AGENCY
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
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and he author' repre ntatives of this County to enter TOTAL, FEE
upo 1 ove-m oned oprelty for inspection p r oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa of Permittee Date