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HomeMy Public PortalAbout5910TEMPLE 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