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Home My Public Portal About5522 GRACEWOOD AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATIO?4 7E 8�1��oJ MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BU LDING AND SAFETY DMSION Insure,, or a certificate of Workers'Compensation Insurance,or , ■certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy Is hereby furnished. "BUILDING LOCALItY ❑ DRE// 5522 Gracewood Ave. Certified copy is filed with the county bullding inspection 11_ OCALITY C NEAREST L department. - 1e i"t CROSS ST. Date Applicant 44KARKST DISTRICT NO. GROUP TYPE PRO E■■ED ■Y CROSS ■T. Baldwin Ave & Live OakCON■r. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL, Q COMPENSATION INSURANCE NSURNCE DLSCRIMT ION LOT NO. BLOCK yAP -WAY No. (clwc�iJ STATE MAJOR IsGOND LOCAL (This „�I,� I, NO. OF BLDGS. \+�� section need not be completed if the work involred TRACT NQSI ON LOT ism ZONE SF/CIAL CONDITIONS ^ . by the permit L for one hundred 'dollars ($100) or ler.) k.OF I1_/J I certify that In the performance of the work for which this uS/�zE OF LOT E%1/TING BLDG, g permit Is ifaued, I shall not employ any person in any manner OWNER V so as to becotne subject to.the Workers' Compensation Laws. AIL OCCUPANCY GROUP AD DREat5522 +L Date Applicant d NOTICE TO APPLICANT:If,'$fter making this Certificate of cITYTemple CityNOL 21 579-6691 OCCUPANT LOAD Z_ Exemption, you should become subject to the Workers' Cgmpensatlon provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit ah All ¢b TRAILER USE GEOLOGY I'N/FRCTION No Spec. Know]. ❑ . deemed revoked. �BnIC OoVICBS ❑ ' LICENSED COISAT TRACTORS DECLARTION OccuPAN.CY"M3-KcON I hereby affirm that I am licensed under provisions of Chapter SAFETY rznurr L 1 (LIST ITEM/ BILLOW) 9 (commencing with Section '1000)of Divjslon 3 of the Busi- No. of Exlr/ n�sa and Professions Code, and my License L In full force and PARKING. e ct. REq'DSPACES PRov1D RD Inanse Number L Lic.Cu_ LIMITED TIME USE tnctdr Date DAT. DAT■ To. .❑ I ■m exempt from the Licensing requirements as I am B . Pwo�: llcened architect or a registered professional engineer ■IzE OF NO. OF INaPECTQR'S acting In my professional" capacity (Section 7051, Bur K 1IFTING BLDG. .TORIES SIGNATURE Incas and Professions Code). PRE/ENT USE OF BUILDING U 146.5 FINAL APPROVAL Lic.or Reg.No. pate I ' HOME OWNER-BUILDER DECLARATION No. OF s2No uaG ■uILDINoe ON LOT AND USE - I hereby affirm that I ■m exempt from the Contractor's _ 2A.925A Llcense Law for the o following reason (Section 7031.5, Busl- 'v o o [i O nese and Professions Code): No. PARKING /PACESPROVIDED I, as owner of the property, will do the work.and the D o 10 0 0 010 ktructure is not intended or offered for sale (Section , . 7044, BUslness and Profmalons Code). RgPOSED USE OF ■UIL.DING �� G L 1J �, 1 3,-82 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ^14 for the performance of the work for w.hlch this permit Is- issued(See. 3097,QIv.C.). Lender'sNema PROPOSED YAx. OCC. Lender's Address PERMIT FEH 25 . 00 " I certify that I have read this application and state that the IaeyANce PGE or above+nformation Is correct.I agree to comply with all County dinances and State laws relating to building construction, TOTAL Fee 25.00 (Pay t0 City of Te' ple City) 3Z!��r f this County_ to enter Inspection p ossa.' /SEE REVERSE FOR EXPLANATORY LANGUAGE Sig."ure of Permittee Da WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self CE 875 (2-80)COUNTY 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 �,- r N f ADDRESS .. ...f. ... ._.,r_...:-. Certified copy is hereby furnished. BUILDINGAve.❑ ADDRESS 5522 Gra ewood f'i eLOCALITY Certified copy is filed with the county building inspection NEAREST department. LOCALITY Temple City a CROSS ST. Date Applicant NEAREST / 4i { DISTRICT NO. GROUP TYPE PROCESSED BY CROSS ST. "+. , .-. ... CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL x,,r c. .r _ y �.�.-........ d COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ZGRWAy O (CIRCLE) ( completede worvoTRACT NOW ON LLOT STATE MAJOR SECOND LOCAL This section need not be if the involved NO. of USE ZONE SPECIAL CONDITIONS U OT by the permit is for one hundred dollars ($100) or less.) USE OF P J SIZE OF LO,T. EXISTING BLDG. I certify that in the performance of the work for which this LL permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL pp� ✓��qq�jI�[+y� p�ep� '{ p#� y� �y OCCUPANCY GROUP ,on gip -. ADDRESS JLL Gracewood 11pIi�ii `i E::::] Date Applicant tr TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tett le C f t No. 1 3 579-6691 OCCUPANT LOAD d Exemption, you should become subject to the Workers' [APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- W with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. 0 NOSpec. KIIOwI. ElOCCUPANCY INSPECTION LICENSED CONTRACTORS DECLARATION °r,�� 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. REQ'D O PROVIDED License Number Lia SPACES Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: TO: 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- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). , •. Pi�AS,E,NT US OF BUILDING rr �,r FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE l 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 , SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the * '} a * 0 structure is not intended or offered for sale (Section 4 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. Lender's Address PERMIT FEE 25.00 rj I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE „ ordinances and State laws relating to building construction, TOTAL FEE +' ( '�v �� :� t7f kt'Tilf� �'3.�y� and hereby authorize representatives of this County to enter -- upon the above mentidnero ty,€or inspection p,yrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date