HomeMy Public PortalAbout5911 TEMPLE 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