HomeMy Public PortalAbout5910 TEMPLE CITY BLVD_Miscellaneous (2) WORKERS'COMPENSATION DECLARATION 76M444 if
CE 875 (2-80) MISCELLANEOUS APPLICATION
I hereby affirm that i have certificate of consent tself I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or I i I
a certified copy thereof(Sec:3800,Lab.C.)
Policy No: Company 1 FOR APPLICANTTO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. I UILDING �y �� �i� J LOCALITY /I°
❑ ADDRESS �7 L, s Com/ P
Certified copy is filed with the county building inspectionI NEAREST
department. 1 LO CALITv /� ,CROSS ST.
Date Applicant EAR ST I �-�Sn DISTRICT NO. G OUP TYPE PRO SEED BY
CROSS ST. `�� / (�'d "Y �1 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J }
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK
MAP �J HIGHWAY
No, (CIRCLE) STATE MAJOR SECOND LOCAL 0
NO.'OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0
by the permit is -for one hundred dollars ($100) or less.) I usE of
SIZE OF LOT EXISTING BLDG. (� Cc
I certify that in the performance of the work for which this i O
permit is issued, I shall not employ any person in any mannerWNER• �� �D�'D G I U
�.
so as to become subject to the Workers' Compensation-Laws. I• AIL �� OCCUPANCY_GROUP 0
LU
ADDRESS Cl)
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY• TOL �7 7� OCCUPANT LOAD
Exemption, you should .become subject .to the, Workers' I 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 Q (LIST ITEMS BELOW)
NO. OR EXITS
9 (commencing with Section 7000)of Division 3 of the Busi- �
.2 as and Professions Code, and my license is in full force and I PARKING
BLfeCt• • REq'D E= PROVIDED
• SPACES
License Number Lic.Class LIMITED TIME 'USE
tl.
Contractor Date
DATE DATE
• 1 FROM: TO:
ElI am exempt from the licensing requirements as I am a I.
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 1/--/,o
-cpLic...or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS G 7 /' (�
ON LOT AND USE r S 0 /,µ.A
I hereby affirm that, I am exempt from the Contractor's �_, A , c G 4 8
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): I NO. PARKING V
SPACES PROVIDED t' o C O 0 o O Z,
El I, as owner of the property, will do the work and the I '
structure is not intended or offered for sale (Section i (1 0 9.1—8W
7044,Business and Professions Code). 14.WPOSED USE OF BUILDING
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. OCC.
Lender's Address PERMIT FEE
I certify that I have read this application and state that the- ti �'
above information is correct.I agree to comply with all County IssuwntcE FEE / Ce�
ordinances and State laws relating'to building construction, TOTAL FEE
and hereby authorizer resentatives.of this County to enter
upon the above-me ned property Inspectio purposes. SEE REVERSE FOR EXPLANATORY
L%OS GUAGE I
Signatureo er tee Da i