HomeMy Public PortalAbout5734 SULTANA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) M I SC E L LA N E O P S APPLICATION
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I hereh-r-,'affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES ' BUILDING AND SAFETY DIVISION
inifure, or acertificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN I BU
ADILDI
DRESS
❑ Certified copy is hereby furnished. UILDING LOCALITY
DRESS 5734 N. SULTANA
O AD ,
Certified copy is filed with the county building inspection NEAREST
department. LocwLlrY TEMPLE CITY CROSS ST.
Date Applicant INEAREST I DIST ICT N G OUP TYPE PR SED BY
CR OSS ST. LAS TUNAS DRIVE ) 8-� TYPE
CERTIFICATE OF EXEMPTION FROM WORKERS" LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK I MAP HIGHWAY
No. QV
NO. OF BLDGS. (CIRCLE) STATE MAJOR SEGO LOCAL a
(This section need not be completed if the WOIk u1VO1Ved TRACT NOW ON LOT r USE ZONE SPECIAL CONDITIONS V
V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify-that in the performance of the•'work for which this O
permit is issued, I shall not employ any person in any manner' wNER JOHN P. WAADE V
so as to become subject to the Workers' Compensation Laws: OCCUPANodAIL CY GROUP
ADDRESS P.
O• BMX 490 W
a
Date Applicant rn
NOTICE TO APPLICANT: If, after making this Certificate of -CITY TEMPLE CITY NO.." 285-2211 OCCUPANT LOAD ?
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. ❑ ❑ qNo Spec. Knowl. ❑❑
1
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (.wsT 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. I PARKING REQ'DPROVIDED
SPACES
License Number Lic.Class
LIMITED TIME USE
Contractor . Date DATE OATH
• . 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 S T
UNAURE
Agwd
iness and Professions Code). I FINAL' APPROVAL
RESENT USE OF BUILDING REAL ESTATE' SALES
Lic.or Reg.No. Date Id I,*
HOME OWNER-BUILDER DECLARATION' 1 NO.OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's � ,s0: 9 a 33
I e $�
License Law for the following reason (Section 7031.5, Busi-' rf
!
nese and Professions Code): NO. PARKING 01,04-845
'
� SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section .i
7044, Business and Professions Code).
i ROPOS RD USE OF BUILDING
CONSTRUCTION LENDING AGENCY REAL ESTATE SALES AND UN-SKRU PRODUCTS
I hereby affirm that there is a construction lending agency `
for the performance of the work for which this permit is I SALES
issued(Sec.30.97,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
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
and ereby authorize representatives of this County to enter ,
UD the above-me lone property for in action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�' • 1-2-85
Si ature of Permittee Date
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