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HomeMy Public PortalAbout5911TEMPLE 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