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HomeMy Public PortalAbout5851TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION ,CE 875(2.80) MISCELLANEOUS APPLICATION 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 a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING pDDRE ❑ Certified copy is hereby furnished. L.OGUILDING -, �'�(/ LOCALITT Y ADDRESS ❑ Certified copy is filed with the county building inspection NEAREST depart me t. OCALITIf d CROSS ST. Date Applicant AREST DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. CONST, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NP HI HWA O (CIRCLE) STATE MAJOR SECOND LOCAL O. NO. OF BLDGS. (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.) USE OF } V 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 NER 4� 0 so as to become subject to the Workers' Compensation Laws. AIL OCCUPANCY GROUP VAI ADDRESS 1 pCL Date Applicant �M .? /��J Q rr�+� / Ca UJ E /C+ I.�I TEL.�IJ V NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICA ION 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 INSPECTION1:1 No Spec. Knowl. ❑ deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I 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. SPACES REO'D O PROVIDED D License Number Lic.Class LIMITED TIME USE C(l ltractor Date DATE DATE t FROM: TO: ❑ I am exempt from the licensing requirements as 1 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). ..p /9ESENT USE OF BUILDING �J �+/J FINAL APPROVAL Lic.or Reg.No. 7 1? 6 Date E /G �• •a 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- C 3 Q,9 A nes:and Professions Code): NO. PARKING { SPACES PROVIDED O o o O 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section D o D D D D D `r 7044, Business and Professions Code). OPOSED USE OF BUILDING r lr.. 9—'o4 4 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.C.). Lender's Name PROPOSED MAX. OCG. 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 tl a bove-mentio d property for Inspe n urpo es. 'SEE REVERSE FOR EXPLANATORY LANGUAGE s Signature of Permittee Dat