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Home My Public Portal About4700 G MILLER DR_Miscellaneous__ -WORKERS'COMPENSATION DECLARATION CE 875(11.84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of comsent to self 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 ILL IN ABUILDING ,/yjl�'J/ DDRESS `l/,t,O /✓ El Certified copy is hereby furnished. BUILDING LOCALITY XX ADDRESS 4700 Miller Dr. c� Certified copy is filed with the county building inspection LOCALITY Temple City NEAEST CR 098 department. XX ST. Date Applicant NEAREST DISTRICT NO. GR UP TYPE ESSED BY DROSS ST. Rosemead & Lower Azusa ,of ,4 IDNS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. HIGH WAYCLE) 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 SIZE OF LOT EXISTING BLDG. 7- 1 certify that in the performance of the work for which this J AIL T permit is issued,I shall not employ any person in any mannelgX OWNER of building 01- %I as to become subject to the Workers' Compensation Laws. sesOCCUPANCY GROUP . ?.:.^, AMDDRESS --' - U Date Applicant _ LLI NOTICE TO APPLICANT: If,after making this Certificate of CITY Temple City NO. 818-5828099 OCCUPANT LOAD v; 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❑ No Spec. Knowl. deeltted revoked. occurwNcr INSPECTION❑ Panic Devices LICENSED CON'T'RACTORS DECLARATION 1 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 an effect. Name of business PARKING RKWO 1 1 PROVIDED SPACES 11--JJJ y �•,, :Si License Number —_— Lic. Class LIMITED TIME U%4J 1 j Contractor Date DATE DATE PROM? ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO.OR INSPECTOR',S SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL /Jq Lic.or Reg.No.— Date PRESENT U96 OR BUILDING t.lq/ VA NOME OWNER-BUILDER DECLARATION NO. OR EXISTING BUILD(NGS ON LOT AND USE 1 hereby affirm that I ant exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING _ 1, as owner of the property, will do the work and the SPACES PROVIDED 9 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCI'ION LENDING AGENCY PROPOSED U86 OF BUILDING 1 hereby affirm that there is a construction lending agency Warehousing 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 _ 1 certify that I have read this application and state that the PERMIT FEE 25.00 A above information is correct.I agree to comply with all County ISSUANCE FEE ordinances a to law .relati o uilding construction, and here author e r nese IV of this County to enter TOTAL FEE 25.00 upon the above-�meflnt pe for inspection purposes. xyx_/ XX SEE REVERSE FOR EXPLANATORY LANGUAGE (' I WORKERS'COMPENSATION DECLARATION fUM444DPW72/90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS'-ANGELES –BUILDING. AND SAFETY DIVISION • ' +insure,or a cerrificatd of.workers'Compensation Insurance,or " a certified copy thereof(Sed.3800,Lab.C.) FILL (� o j�7 company �'Ct�2 C4yV1 ✓6�Ci�(Ot� FOR APPLICANT TO FLL IN BUILDING Policy N •' , •. i jyi�y��q � r,t�:( BUILDING ADDRESS � ADDRESS ❑ Certified copy.is hereby:furnisl�jie i $ 94-700 Y�L I4�r' UPS LocALITY ❑ Certified copy is filed with the county building inspection CITYZIP NEAREST t department 2679 Q l n: / CROSS ST. Date Applicant SIZE OF LOT I rNO.OF BLD .NOW ON LOT DISTRICT NO. GROUP TYPEPROCESSED BY O CERTIFICATE OF EXEMPTION FROM WORKERS' OD 0 coNST. C 1 ) COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP H (, . No. (cIRCLE)lncl.et STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS Ot by the permit is for one hundred dollars ($100) or less.) TEL NO. t I.certify that in the performance.of the work for which this �� er g tr,SSf7'" LL permit is issued. I shall not employ any person in any manner _ l so as to become subject to the Workers' Compensation Laws. ADDRESS -, a .L �,� OCCUPANCY GROUP v: ( i Date Applicant CITY ZIP NOTICE TO APPLICANT. If. after making this Certificate ✓ �_ OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-I 6or Code.you must forthwith EXIT HARDWARE: ( comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec.Knowl. ❑ ' revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) t I 9(commencing with Section 7000)of Division 3 of the Business 11 1 KaO usiuess NO.OF EXITS and Professions Code,and my license is in full force and effect. License Numbe) LIC.Class PARKING• REQ'D � PROVIDED SPACES ' LL��J i & 7]G . l I I Contractor— Date LIMITED TIME USE I ❑ I am exem 7t from the licensing requirements as I am a •• DATE DATE licensed architect or a registered professional engineer FROM: o: acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S and PIOfeSSIOnS Code). EXISTING BLDG. STORIES P SIGNATURE. Lic. or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL i HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and 1 Professions CodE): NO.PARKING ❑ ' SPACES PROVIDED I, as owner of the property, will do the work and the i structure is not intended or offered for sale(Section 7044, PROPOSED USE OF BUILDING Business anj Professions Code). i 1 CONSTRUCTION LENDING AGENCY I' (n- 77 atiL i 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.). PROPOSED MAX.OCG Lender's Name_ APP CANT(ERrNr) TEL NO. I t l••� Lender's Address ADLTRESS j I certify that I have read this application and state that the O D �l��Q/ ✓• above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,;and hereby authorize representatives of this County to enter upon ISSUANCE FEE , the above-mentioned property for inspection purposes. I i S I •`,. ,; TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE LSignatu a of Permittee Date