HomeMy Public PortalAbout5561 SULTANA AVE_Miscellaneous__ RS'COMPENShTiONDECLARATION
CE 875(2 80) MISCELLANEOUS APPLICATION {�
CE 876 u
I UCaftt-z that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure r n py there of Workers Compensation Insurance or
epern�d ropy thereof(Sec 3800 Lab C ) ,
�p rVl • •
Policy No Company `� FORAPPLICANT TO FILL IN BuILDING
❑ ADORE„ 561 Sultana Ave
Certified copy ,s hereby furnished amLOInG LOCALITY Temple City
r_1
woow¢NE 5561 Sultana Ave-
Certified copy a filed with the county budding mspectio
NEARMOT
department Locwurr Te1Bp1e City EROSE ET L84 Tunas
Date Applicant N6wpCaT DISTRICT N OROUr TYP¢ PRO CalfiO ¢Y
cpoa, IT Las Tunas JO 5% cox.T
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE D¢SCRnnON LOT No BLOCK II���a // IDLRw
NOr.20,04 - (e1R eLeI STATE MAJOR SECOND LOCAL a
(This section need not be completed If the work InvolvedTRACT NONOH OON LOT LOTOF use ZONC U SPECIAL CONDITIONS O
by the permit is for one hundred dollars (5100) or less) LSE or 3
SIZE or LOT ¢x,,TING ¢Loa 2
1 certify that in the performance of the work for which this, Wan Teh Tsai
FO
permit 6 issued, 1 shall not employ any person in an manner OWNER �f
so as to become subject to the Workers Compensation Laws MwIL OCCUPANCY GROUP /f LU
L)ADURH„ 114 So. Wnterre J -a
Date Applicant to
NOTICE TO APPLICANT If after making this Certificate *C, CITY Alhambra 91861 NoL 28 — 008 OCCUPANT LOAD z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth APPLICATION FOR EXIT HARDWARE
with comply with such provus,ons or this permit shall be TRAILER U,¢� GEOLOGY INSPECTION
deemed revoked NO Spec KnOwl El
LICENSED CONTRACTORS DECLARATION OCCUPANCYINePEcr1ON Panic Devices ❑
I hereby affirm that I am licensed under provisions of ChapterawF¢Tr Peewrc (LIST ITEMS Eelo,il r no or EXITS
(commencing with Section 7000) of Division 3 of the Bust
ness and Professions Code and my license Is in full force and Pw Rp,nG
effect R¢o o vR ovlD¢D
n
aPwc¢¢
License Number LIc Class
LIMITED TIME USE
Contractor Date F.r. DATE
❑ PwoN
I em exempt from the licensing requirements as I am n
licensed architect or a registered professional engineer mzC Or NO OF INSPECTOR a
acting ,n my professional capacity (Section 7051 Bus EXISTING BLDG ,TORIES SIGNATURE
Inas and Professions Code) FINAL APPROVAL
PRLS¢NT USE OF BUILDING A fr O
LIc or Reg No Date f•� J a J
HOMEOWNER BUILDER DECLARATION NO oN LOT AND
Bu1LOIxoE
USE
NE ,
1 hereby affvm that 1 am exempt from the Contractor's
s
License Law for the lollovnng reason (Section 7031 5 Bull 2 9 (f
ness and Professions Code) NO PARKINS
❑ SPACES PROVIDED # e D P a 3 G
I as owner of the property will do the work and the r `"
structure Is not Intended or offered for sale (Section o P A 8 Q 5
7044 Business and Professions Code)
Pporoaeo u,e or BUILDING
j' aDPEJO
CONSTRUCTION LENDING AGENCY ` r
1 hereby affirm that there Is a construction lending agency 07,24 -84
for the performance of the work for which this permit Is
wued(Sec 3097,Civ C)
Lenders Name
Peoro,ED MAX occ
Lender's Address PERMIT FEE 0 '
1 certify that I have read thus application and state that the
above information B correct I agree to comply with all County ISSUANCE FEE H-OO
ordinances and Slate laws relating to building constructionTOTAL FEE and hereby authortre representatives of this Coonly to enter
upon he above y,entioned pr erty for in on rposes �E E REVERSE FOR EXPLANATORY LANGUAGE
SignatuaAf Permrtt,115 ate /