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HomeMy Public PortalAbout5919TEMPLE CITY BLVD_Miscellaneous (2) i •�•1 WORKERS'COMPENSATION DECLARATION CE 878(1 1-84) MISCELLANEOUS A P P L I C AT I O N , • insure, o affirm that I have a certificate of consent Insur tc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION i I insure, or a certificate of Workers'Compensation Insurance,or • a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING G� ADDRESS Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS t PAIC Certified copy is filed with the county building inspection LOCALITY NEAREST department. Temple City CROSS ST. Date Applicant NEAREST DISTRICT NO. GROJjP TYPE ESSED BY GROSS ST. Lae. ImAs GA LEGAL • CONST. I CERTIFICATE OF EXEMPTION FROM WORKERS' (/a /y�� r I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP HIGHWAY I H E ) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF 1 SIZE OF LOT EXISTING BLDG. ' 4'•� i I certify that in the performance of the work for which this C, permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP & c Date Applicant ADDRESS �� TEL. �� NOTICE TO APPLICANT: If,after making this Certificate of CITY !,e NO. OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLI ATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONIX Panic Devices I 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- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REO'D PROVIDED License Number Lic. Class SPACES 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 SIZE OF No. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TUR iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O ON LOT AND USE O �''� I hereby affirm that I am exempt from the Contractor's �� / j III —i3fj(<1 2f 8/99 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 2418 AN �'F �j I, as owner of the property, will do the work and the SPACES PROVIDED I'41i1S1A � structure is not intended or offered for sale (Section 7044,Business and Professions Code). //t CONSTRUCTION LENDING AGENCY X 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.C.). Lender's Name PROPOSED MAX. OCG. Lender's Address I certify that I have read this application and state that thPERMIT FEE '25.00 e above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, r and hereby authorize representatives of this County to enter TOTAL FEE 25.00 •,.1 I upon the above-menti leiproperty for inspection purposes. • S ZI -57SEE REVERSE FOR EXPLANATORY LANGUAGE ' j Signature o Permittee Date