HomeMy Public PortalAbout5909 TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION CE 8754(11-84) MISCELLANEOUSAPPLICATION
I hereby affirm that I have a certificate of consent to self
insufe, or a certificate of workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION fl
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
® Certified copy is hereby furnished. BUILDING
•ADDRESS LOCALITY
Certified Copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DIST T_N GR UP TYPE / PROCESSED BY
•� CROSS ST. �(r/1 ,Z CONST. eV// (/yCA
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L�
COMPENSATION INSURANCE DESCRIPTION ILOT NO. L3 BLOCK MAP HIGHWAY STATE MAJOR SE ND LOCAL
NO. (CIRCLE)
NO. OF SLOGS.
(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. V- a
I certify that in the performance of the work for which this , o,
permit is issued,I shall not employ any person in any manner V OWNER 0� rid—
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS [ Z3
Date Applicant U1
NOTICE TO APPLICANT: If, after making this Certificate of V CITY za.-0- v No�' OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION 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 INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
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
EJI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: TO: INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). ii FINAL APPROVAL
Lic.or Reg.No. Date V PRESENT USE OF BUILDING Q 6
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-
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 ;2 6 8 7.9 A
7044,Business and Professions Code).
\J PROPOSED USE OF BUILDING # o o o O 8 8
CONSTRUCTION LENDING AGENCY i
I hereby affirm that there is a construction lending agency Ari o/^ o 0 0 0 0 0 o z
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). 0 &2 0=8 7
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 f1
ordinances and State laws relating to building construction, VV
and hereby authorize representatives of this County to enter TOTAL. FEE ,qu
S
upon the above-mentioned property for inspection purposes. (t \v�\
SEE REVERSE FOR EXPLANATORY LANGUAGE �/ a
Signature of Permittee Date