HomeMy Public PortalAbout5839TEMPLE CITY BLVD_Miscellaneous I WORKERS'COMPENSATION DECLARATION' 8 a M ISCELLANEOLIS APPLICATION
CE 87
I hereby affirm that 1 have a certificate 'I I-consent CE 11 841
ent to self _
insure, orr) certificate of Workers'Compensation Insurance.or COUNTY OF LOS .ANGELES ; BUILDING .AND SAFETY DIVISION t
a..MvUtied copy;thereof iSec.3800.Lab.C.I. _ `J
3 (' FOR APPLICANT TO FILL IN BUILDING
Policy No._—Company f
,ADDRESS OXY 6Z!EW
Certified copy is hereby furnished. g 13U IL ��p ) r C /� t n D• _
ADDRESS OO 77 - LOCALITY
1 FICertified :opy is filed with the :otint% building inspection LOCALITYNEAREST
department. Temple City CROSS ST.
Date—Applicant NEAREST DISTRICT NO GR PTYP CESSED BY
CROSS ST. I •D G (CONST
CERI71FIC_\TE OF EXEMPTION FROM WORKERS' LEGAL a
I (ONIPE�S.\TION INSURANCE DESCRIPTION LOT NO. I BLOCK MAY .+IGHWAY
No. [CIRCLE) STATE MAJOR SECOND LOCAL
_F-_
OOF SLOGS.
(This section need not he completed if the work involved I-RACT NO�V ON LOT USE ?:ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars IS100) or less.! USE of '
SIZE OF LOT I EXISTING BLDG.
1 certify that in :lie performance Of 91e a.?r4 :u:Which 91iS _
permit is issued. I shall :lot employ any +o:con :n any manner owNER .+ Art, !!id
so as to become stlniect :o the WorkersC::»pensatioa 1.:lit,. ,;AIL J OCCUPANCY GROUP
Date ►pelican[
ADDRESS TL Cr E , I I –
t • •_
NOTICE To APPLICANT: If,after makinc :his Czrtiticat � 3c of $I arr-, Q 1 vo.' f� Z OCCUP4N-LOaC
Exemptio:t. you ;hauld become cui?iect :a rho tCmkers• A !CA711-N CC'R li cX1'HAROW-1FE
Comeensirion provisions of rhe Labor;-ode. %.oil must toull-
! ivith (omni}• with Duch nr visior; or his -ermir ;hail he
-RAILaR :J3E ] GEOLOGY :NFPE.:T ICY � I No SDeC. I I�:l(`/I,
deemed rel Irked. ❑
OCCUPANCY INSPECTIONgg Panic Cevtres
LICENSED CONTRACTORS DECLARATION i
I hereby aitlrnt :(lit 1 alp llcensedunder DCCvIsIOnsA[('llaDleL SAFETY PERMIT (
LIST ITEMS SELOVII
1 9 (c1 nitn.encine with Section 0001 of Division J it the iBusl- NO. OF EXITS
:V
ness and P-nfcsdom Code.and my license i, :n :i:il giro: and
effect. SPl PARKING REO.O I I PROVIDED
5 4CE5
5 License N(tnll?er. _— Lic. (-las, LIMITED TIME USE
HContractor ..._. --.–_--_--- Ilate—.–.._-__.-.–..._.---_ DATIE 0ATr:
W
-L F i^-M: TO:
I and exempt from the :icensine requirement, as I im .I 1
m 1 licensed Architect or a re;istered nrnfession:l_l engineer ;IZE of .Io. o� INSPEC OR•S
z Actin_ in •ny prote!,4onal ar:lzit�� se:-.ion Il:1.1 sill;- EXISTING SLOG. 5T 7RIE7 T
51 TURE
inessLind P:Ufessicn%Cadel• FINAL APPRAIVAL- _ I -- I----
Ci 'RESENT USE OF BUILDING
Lie.or Rea. No. -- -- Da-io---'—. /A /v A
HOME OWNER-BVILDL••R DECLARAHON NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that 1 ant exempt frons the Contractor's
I License Lase for the followint_ reason (Section -1131.5. Busi-
ness and Professions Code): NO. PARKING '
SPACES PROVIDED
1. as owner of the property. will du :he work .un the
structure is not intended or offered for ;.lie ISepion
1 7044.Rusinecc and Professions Code). I
CONSTRUCTION LENDING AGENC% � PROPOSED USE OF BUILDING �
hereby affirm that there is :1 construction lending amence
1 for the performance of the work for which this perrut is 1
issued ISec. 3097•Civ.C'.).
Lender's Name.__--. _.—_-- r .
PROPOSED MAX. OCC.
Lender's Address �—
( [ certify that I have read this application and crate tha4 the
PERMIT FEE 25.00
above information is correct.I aeree to comply with all County ISSUANCE FEE 1�)
ordinances and State laws relating to building construe tion.
and hereby authorize representatives o ltis County to tenter TOTAL FEE 25.00 �11
upon the aboee-mentioned prWyi (tion purposes..� SEL RL"\'ERSi: FOR E\PLAN:\TORI'LA?VGU:\GC.Signature of Pern' Date
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