HomeMy Public PortalAbout5851TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION 76M444
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 ��
ADDRESS
❑ Certified copy is hereby furnished. I BUILDING 1 LOCALITY L
DRESS
❑ Certified copy is filed with the county building inspection NEAREST
department. I LOCALITY CROSS ST.
Date Applicant NEAREST 1 DISTRIC NO. O TYPE PROLE SED BY
I CROSS ST. I CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ! 0
DESCRIPTION LOT NO. BLOCK
COMPENSATION INSURANCE
;MA IGHwAT STATE MAID"SECOND LOCAL }'
IND.. ,o CIRCLE) a
,NO. OFLOT USE ZONE SPE IAL CONDITIONS
(This section need ilot.-be completed if the work involved TRACT Now ON Lor �. _
by the permit is for one hundred dollars ($100) or less.)
USE of I
1 SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner OWNER / N
so as to become subject to the Workers' Compensation Laws. I MAIL I OCCUPANCY GROUP141
DDRESS �' M
Date ApplicantTE
r/1
NOTICE TO APPLICANT: If, after making this Certificate of IrY I L 1 NoL ( Z I OCCUPANT LOAD
Exemption, you should become subject to the Workers'
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 C No Spec. Knowl. ❑
deemed revoked. Panic DeVIC25 ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION j
I hereby affirm that I am licensed under'provisions of Chapter SAFETY PERMIT Q (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 PARKING.
effect' ; - .SPACES ' REQ'D D PROVIDED D
License.Number Lic.Class LIMITED TIME USE
Contractor Date 0Are• DATE
❑
FROM: To:
lam exempt from the licensing requirements as I am a. t
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). FINAL APPROVAL
PRESENT USE OF BUILDING fir.( r1�
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 ; f 4 6 3,61V
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
'o
SPACES PROVIDED eDD ,88
❑ I, as owner of the property, will do the work and thea ZM
structure is not•intended or offered for sale (Section I o I o 0 0 0 0.z
7044,Business and Professions Code);
, PROPOSED USE OF BUILDING ..0 8, 1 9-83
CONSTRUCTIONIEN DING AGENCY i
I hereby affirm that .there is a construction lending agency D
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address PERMIT F S TI 0
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, 1 TOTAL FEE i
and hereby authorize representatives of this County to enter
up the above-mentioned property for inspectio /purp sea. SEE REVERSE FOR EXPLANATORY.L'ANGUAGE
I
Sig nWure of hrmi ate f
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