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HomeMy Public PortalAbout5911TEMPLE CITY BLVD_Miscellaneous WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS CPPLICATI®N 1 hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFE'T'Y 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. pDILDIN �" 4. I'- LOCALITY OC ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. � + llate Applicant IV ASRSFST ST. 4,y�.y� DISTRICT N GROUP CYOPE PROC SED®Y CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �� �1 COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY ? STATE MAJOR SECOND LOCAL } (This section need not be completed if the work Involved NO. CO BLDGS. USE ZONE SPECIAL CONDITIONS 0 P TRACT NOW ON LOT Q by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. 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 OWNER so as to become subject to the Workers' Compensation Laws. AIL ; OCCUPANCY GROUP t ADDRESS /)/�/j I? Date Applicant TEL. Cn NOTICE TO APPLICANT: If, after making this Certificate of TTY No. OCCUPANT LOAD z_ 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. Cl No Spec. Knowl. 41 LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ❑ 9 (cyrlmencing with Section 7000)of Division 3 of the Busi- nesspPpIKING. and Professions Code, and my license is in full force and effeL�t. SPACES REQ'D O PROVIDED D License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as 1 am a. 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 inessand Professions Code). 0. ESENT USE OF BUILDING FINAL APPROVAL �-. C�] •C1 `p ,' ! '�Gr� Lic.or Reg.No. Date V r ! HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE '� n I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- " a D D D nese and Professions NO. PARKING ssions Code): SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the D o o a 'r structure is not intended or offered for sale (Section 7044, Business and Professions Code). (' [i C c _ ROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY �p I hereby affirm that there is a construction lending agency r /- / 0 r' 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 1 have read this application and state that the above information is correct.1 agree to comply with all County ISSUANCE FEE � ordinances and State laws relating to building construction, r , 6� T e1 and reby uth'orize representatives of this County to enter TOTAL FEE �7 D� 9Y � �7/ gw%o- o nn h above-mentio pr y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Permitt Date