HomeMy Public PortalAbout4331 1/2 TEMPLE CITY BLVD_Miscellaneous__ „ WORKERS'COMPENSATION DECLARATION
CE 875 It Lila) MISCELLANEOUS APPLICATION r1
+ CE 976
1 hereby affirm that 1 have a certificates'Co ate of consent to telt COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
illalre er acertificate of Workmi Compensation Insurance,or
a certriled copy thereof(Sea 3800,Lab.CInsurance, .
Polley No. Company FOR APPLICANT TO FILL IN sulLohxo
ADORste
❑ Certified copy is hereby furnished. EUILDiNo 4 —a
AGowsu eco urr ,
ElCertified copy is filed with the county building inspection LOCALITYnsww ST
department. cwouEsr.
Date Applicant BAREST ` ` DISTRICT no. our r PwocausD BY
CROSS RT. li �� ccN
CERTIFICATE OF EXEMPTION FROM WORKERS' Ls_wL
COMPENSATION INSURANCE DESCRvnC” LOT No. BLOCK •P '""B STATE MAJOR SECOND LOCAL
no.or 81.06S. No. /—w elwc I
(Thio section Deed not be completed if the work involved rwwcr NOB on Lor USE nE nseuL conorrxonS
by the permit is for one hundred doll= ($100) or lea) uss or
1 certify that in the performance of the work for which this nAK Or LOT ExheTING BLDG. M—
permit is issued,I shall not employ any person in any manner o.Ru L ail
Y
so as to become subject to the Workers'Compensation Laws AIL OCCUPANCY GROUP,15
¢
110 �1 O
Date AD OR Eta Applicant W
ro
NOTICE TO APPLICANT: If,after making this Certificate of Irr no,L.. Y L} I OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you most forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit than be TRAILER USE GEOLOGY INSPECTION
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION �' Panic Devices
I hereby affirm that 1 ern licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the BusF aw.Er. PERMIT ❑ (LISP Yrs MS ESLD.) NO. or EXITS
riots and Professions Code,and my license is in full form and
effect. PARKING wE0'O PROVIDED
SPACKB
Contractor-
Number Lia Clan LIMITED TIME USE
Contractor Date CATS DATA
❑ I am exempt from the licensing requirements as I am a •Ro.. Vol
licensed architect or a registered professional engineer Sns or no.or INSP%CTVR•S
acting in my professional capacity (Section 7051, Bus- B STINa _Loa. STOwIb SJG ATURE
iness and Professions Code). FINAL APPROVAL . 7 /—
Lia or Reg.No. Date RsasnT USE Or BUILDING Z—i
NOME OWNER-BUILDER DECLARATION NO.Or EXISTING MAING
ON LOT AND USK
I hereby affirm that I am Exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busl-
ness and Professions Code): No. PARKING q $5 9 Q 7 A
F11, as owner of the property, will do the work and the SPACES PROVIDED (' # S S S 688
structure Is not intended or offered for sale (Section
7044,Business and Professions Code). � S S S S S S S j 1
CONSTRUCTION LENDING AGENCY �i
PROPOSED USE or BUILDING N 1.20-86 O_8 6
1 hereby performancefffnn that there b e conn lending agency 11
for the performce of the work Coror which this permit b `
issued(See 3097,Civ.Q.
Lender's Name
PROPOSED MAX. Dec.
Lender's Address
I certify that I have read this application and state that the I PERMIT PEE s;00
above Info n b coned 1 agrm to compply wish all County roauwncE was
a to laws rclatirlg to buhld construction,
an a thor e rc atives of fhb ounty to emm TOTAL res �db
e a nth rty for n pts
✓SEE REVERSE FOR EXPLANATORY LANGUAGE
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