HomeMy Public PortalAbout4303 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION certificate
of co sent CE875 41280) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have a Certimpen of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION i
' insure or S certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN eU1Lm Na "� / if -
El Certified copy Is hereby furnished emLmne .� .� Ji U41,4
l�� wooALIT .� ,. %— J (I-
El
,..
❑ ADDRESS I �� (�� / U4 OC ALITY Jit Cr
department
copy Is filed with the county budding inspection �r,)), l! � C17 3
department LOCALITY r rL�L- r cnoee TIT r �'
1Date Applicant !, NEAR esr Die�rg ICT NO a uP Tree • cesweo BY
CROSS Sr
1
CERTIFICATE OF EXEMPTION FROM ' RKE RS LeawLcox -e-roti 1
COMPENSATION INSURANCE j -DESCRIPTION LOT No eLoeX_ I ryoP — mNrA _ - OU
_ __ __ _ _ _ IuncLcl - STATD_.AJOR SECOND LOCAL _ W _
-
(This-r tion need not be coin leted if the work involved _ - NOWCO BLT —' USE ZONE SP ECt AL CONDITIONS J
P TRACT NOW ON LOT
by the permit a for one hundred doBaro ($100) of leas) USS of a
I I certify that in the SIZE OF LOT QXI TING BLDG
cc
performance of the work for which this _ cc
permit a issued, 1 shall not employ any person'm any manner orv.QR f 4L- Q
so as to become subject to the Workers Comp—m-w. Laws MAIL ,3/� G f r Y_ OCCUPANCY GROUP y,.r.1 a:
ADDRESS
Date ApplicantT _ d
NOTICE TO APPLICANT If after making this Certificate of CITY / /-lIy E Cl/ TEL
—� "�' ' OCCUPANT LOAD
Exemption you should become subject to the Workers LU
.-Compensation provisions of the Labor Code, you must forth APPLICATION FOR EXIT HARDWARE
With comply with.such provisions Or this permit shall be TRAILER USE C] GEOLOGY INSPECTION KnOWI ❑
deemed revoked Cl No SpA P
' LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SwPQTV PERMIT (LIST ITEMS BELOW) NOOF Q.ITS
1 9 (commencing with Section 7000) of Division 3 of the Bust
tress and Professions Code and my license is In full force and PARKING effect
- SPACES RQp D D PROVIDED
License Number ' Lic Class
1 LIMITED TIME USE
Contractor Date Are OAT.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer n29 or No OF INSPECTOR a
acting in my professwnal capacity (Section 7051 Bus- EXISTING SLOG J STORIES SIGNATURE
mess and Professions Code) 1 '• PRESENT USE OF BUILDING (�`� �// �" r FINAL APPROVAL
Lic or Reg No Date—
HOMEOWNER
ateHOMEOWNER BUILDER DECLARATION No OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractors '
License law for the following reason (Section 7031 5, Bust _�� $ H ii'S • ♦ S r;
nese and Professions Code) No PARKING SXIxa
SPwcRe PEOVmED • R;S • • S9
ID 1 as owner of the property will do the work and the I
structure is not intended or offered for sale (Section _ ///// l rr
7044 Business and Professions Code) + PROPOSED USE OF BUILDING/0q1-1-&—T IM&6 i0 a ` 7dj
CONSTRUCTION LENDING AGENCY
I hereby afftrm that there is a construction lending agency
for the performance of the work for whwh this permit is N
issued (Sec 3097 Civ C ) 1
Lender's Name 1
PROPOSED MAX OCC
Lender's Address PERMIT PEE 1 '
F
1 certify that I have reed this application and state that the
above information a correct I agree to comply with all County ISSUANCE FEE City
p
ordinances and State laws relating to building'construction TOTAL FEE $25 .00 (Pay to C I ty Of , Temple City) '
and hetEby authorize r resentatives of th County to enter
upo Fhe eboveyDen �d pro f ,�s'pect ton pun 0sps 58E REVERSE FOR EXPLANATORY LANGUAGE
�-� f�
Signature of Permntee Date