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Home My Public Portal About5326 BARELA AVE_Miscellaneous__ WOR cERS'CC9MPENSATION DECLARATION CE 876(2-80) MISCELLANEOUS APPLICATION i hereby affirm that I have certificate of consent nself COUN'T'Y OF LOS ANGELES BUILDING AND SAFETY 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 /^/�J ADDRESS �3pC ❑ - Certified copy is hereby,furnished. BUILDING LOCALITY ADDRESS'- L� El Certified copy is filed with the county building inspectionala NEAREST ,.department. - LOCALITY Temple City CROSS ST. "[,/ Date 'Applicant NEAREST 1 DISTRICT NO GROUP TYPE PROCESSED BY CROSS ST. s, CDNS_T�( CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION 'LOT NO. - BLOCK STATE MAJOR SE OND LOCAL COMPENSATION INSURANCE 16 NOP ru�Rwwv 14210 . NO. CO BLOCS. NO. (CIRCLE) d (This section need.not be completed if the 'work involved TRACT NOWCON Lor 2 USE ZONE SPECIAL CONDITIONS ,by the permit is for one hundred dollars,($10,0) or less.) - USE of U I certifythat m the srzE OF LOT 55.'.x16.0 '- EXISTING BLDG.- res. / performance of the work for which this 9 permit is issued, I shall not employ any-person'in any manner ""'William J.. & Ph l l i s C. . OWen ~ so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP MAIL ADDRESS Date 10-1 9—$s7pticant5326. No. 'Bare-la- Ave. TdT7 1'1; am 'J Owen v) TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY Temple C NO. _ OCCUPANT LOAD oug 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. ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I'hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000).of Division 3 of the Busi- ness and Professions Code, and my'license is in full force and effect. PARKING: ' P SPACES REO'D E= PROVIDED License Number. Lic.Class LIMITED TIME USE Contractor Date DATE DATE '❑ FROM: TO: Lam 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- EXISTING BLDG. STORIES 1 GNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL res. & storage -zz� ,Lic..or Reg:No. Date . .,. . 30 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGSON LOT AND USE 2. - res. & Stora e - I 8050 I hereby affirm that, I am exempt from -the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING xo SPACES PROVIDED _ . I', as owner of the property, will do the work and the „I '0.2 2*87 structure is not intended or offered for sale, (Section 7044,-Business and Professions Code). PROPOSED USE of BUILDING CONSTRUCTION LENDING AGENCY 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: OCC. I. Lender's Address PERMIT FEE . I certify that'I have read this application and state that the C ` above information is correct.I agree to comply With all County ISSUANCE FEE V ordinances and State laws relating to building construction, TOTAL FEE and Mhee-men orize rep s atives of this County to enter `up nti'ep rl erty for,inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 10-19-g7. Signature of Permitte Date