HomeMy Public PortalAbout5911 TEMPLE CITY BLVD_Miscellaneous (2) -.1NORKEPo ,'COMPENSATIONDECLARATION cE87fi41t1- 84) MISCELLANEOUS APPLICATION '
I hereoaffirm that I have a certificate of consent tself
insure;or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISIONe,or a
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING C!/ �' m P ' 8luD L
XX ADDRESS 77 L e LOCALITY
Certified copy is filed with the county building inspection LOCALITY C DG G C( 7-Y NEAREST
department. Xx �L rcRoss sT.
Date Applicant NEAREST / DISTRICT NO. UP TYPE S.
BY
CROSS ST. Y\ S TO/Y!f S 0� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK NG. HIGHWAY STATE MAJOR SECOND LOCAL
NO.OF BLOCS. (CIRCLE)
(This section need not be completed if the work involved I TRACT Now ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) I USE OF
I certify that in the performance of the work for which this i SIZE OF LOT EXISTING BLDG. o
D_
permit is issued,I shall not employ any person in anymannesXX owNER of buildin P �/\p EL Mile
so as to become subject to the Workers' Compensation Laws. 1MAIL i/a,/ AI ) ` p I OCCUPANCY GROUP U
Date Applicant ADDRESS? 7"/V /� `�' �CG�Q
NOTICE TO APPLICANT: If,after making this Certificate of
CITY/ v p�N q �o NEoo(J 31pO�o�31p OCCUPANT LOAD y
Exemption, you should become subject to the WorkersAPPLICATION 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❑ No Spec. Knowl.
deemed revoked.
OCCUPANCY INSPECTION❑ Panic Devices
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code,and my license is in full force anixl Name of busineds PARKING '^I
effect. SPACES REQ'D PROVIDED —J
L ^ FyJ J
License Number Lie. Class i TK 7
LIMITED TIME USE
Contractor Date DATE DATE
FROM? O:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- I EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). FII4AL APPROVAL
Lie.or Reg.No. Date I PRESENT USE OR BUILDING /
HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS w_w
ON LOT AND USE :J
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- I Uf E1=)'Ilsl t rYIIE `'
ness and Professions Code): NO. PARKING
I SPACES PROVIDED Ii178 1 �71
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section "
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY I PROPOSED USE OF BUILDING
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.Q.
Lender's Name
PROPOSED MAX.OCC.
Lender's Address
I PERMIT FEE 25.00
1 certify that I 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,
and hereby—authorize repress tives of this County to enter TOTAL FEE 25.00
"upon fl ab ve-menti d p rty for i ection purposes.
XX XX SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date