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HomeMy Public PortalAbout5910TEMPLE CITY BLVD_Miscellaneous I WORKERS'COMPENSATION DECLARATION 875(2-SO)a 11 1 CE M ISCE LLANEOUS APPLICATION CE 87 I Hereby affirm that i have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or I , a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company I BUILDING FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is hereby furnished. UILDING �s J ADDRESS ji� lT J/ 1AA1,0 LOCALITY ❑ Certified copy is filed with the county building inspection Lo I a //" NEAREST department. LOCALITY / r CROSS ST. Date Applicant ONEARESTDISTRICT NO;;1 'OUP TYPE' PRO. SSED BY CROSS ST. `�� v/I'•� ✓ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK } NOP �Q" (CIRCLE) STATE MAJOR SECOND LOCAL IL (This section need not be completed if the work involved NO.- F BLOGS. TRACT NOWOO ON LOT USE ZONE SP CIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG- cc 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 WNER, ei. 4f/� ADD G V so as to become subject to the Workers' Compensation Laws. AILOCCUPANCY_GROUP 0 ALo 41LU DDRESS lee� CO Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of .I CITY• TEL �� OCCUPANT LOAD z Exemption, you should become subject. 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 �.I TRAILER USE GEOLOGY INSPECTION deemed revoked. J+I ❑ ❑ No-Spec'. Knowl. ❑ • LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L I (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- r ss and Professions Code, and my license is in full force and PARKING effect' SPkCES ' REQ'D PROVIDED .License Number Lid.Class LIMITED TIME'USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: 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). EFINAL APPROVAL /} SENT USE OF BUILDING Lic,or Reg,No. Date 1,0 ` c HOMENO.OF EXISTING BUILDINGS V OWNER-BUILDER DECLARATION ON LOT AND USE I `_ Q 7, 4 A I hereby affirm that- I am exempt from the Contractor's t r o a 0 0 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ( NO.PARKING SPACES PROVIDED Q o c o 0 0 0 M ❑ I, as owner of the property, will do the work and the I' ' ' ' structure is not intended or offered for sale (Section (i 11091-814 7044,Business and Professions Code). POSED USE OF BUILDING 5 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for wJtich this p permit is. i issued(Sec.3097,Civ.C.). Lender's Name I PROPOSED MAX. OCC. ' Lender's Address PERMIT FEE - I I certify that I have read this application and state that my ISSUANCE FEE � I + � above information a correct.I agree to t comply with all County _ ^ ordinances and State laws relating to building construction, TOTAL FEE .12- 15-1040 /%/GAY{,/ and hereby authorizer resentatives of this County to enter & I upon the above-me ned property f inspectiop pur oses. SEE REVERSE FOR EXPLANATORY�fAGE !/� Ii/ / ✓/ Signature o er tee Da