HomeMy Public PortalAbout5919 TEMPLE CITY BLVD_Miscellaneous WORK(;RS'COMPENSA7'ION I)L(:LAItA'l'lON CE 875 MISCELLANEOUS APPLICATION
CE 87.ri(17 84) i
I heivbo affirm that 1 have a certificate of consent to self COUNTY OF LOS A G BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL BUILDING ADDRESS ,_�/�
Certified copy is hereby furnished. BUILDING
ADDRESS 5919 Temple Cit Blvd. LOCALITY
Certified copy is filed with the county building inspection ICALITY NEAREST
department. Temple City CROSS ST.
Date Applicant NEAREST DISTRICT NO. GRCCCyyyUP TYPE CESSED BY
CROSS ST. -If-d
`,(( CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 'vt
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OR LOGS. No. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ONBLOT USE Z6NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT (STING BLDG.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner OWNE
so as to become subject to the Workers'Compensation Laws. MAIL �—� OCCUPANCY GROUP
ADDRESS V .•
Date Applicant
NOTICE TO APPLICANT: If,after making this Certificate of CITY . No.' 26- 286-551 OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- JFa 6,66 APPLICATION FOR EXIT HARDWARE:
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 affirni that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
nesend Professions Code,and my license is in full force and /
effect. !% PARKING
SPACES REqD E. PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer i SIZE OF NO.OF _ INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN UR
iness and Professions Code). i
Lic.or Reg.No. Date I
PRESENT USE OF BUILDING FINAL APPROVAL 3l9
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Mv/� I ?�FEE i��I�ON LOT AND USE s986 M10!10
I hereby affirm that I am exempt from the Contractor's oyD!/( ! ((�� 2986 �`
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY 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
Lender's Address PROPOSED MAX. OCC.
I certify that I have read this application and state that the PERMIT FEE 07"
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
.and hereby authorize representatives of this County to enter TOTAL FEE
upon the ovc- entioncd property for in pection purposes.
Sl:li RIiVI'161:FOR IsXPLANA'l'ORY LANGUAGE
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Signature Permittee Date