HomeMy Public PortalAbout4333 TEMPLE CITY BLVD_Miscellaneous__ WGRKERS COMPENSATION DECLARATION
CE 875(11 84) - MISCELLANEOUS APPLICATION {1�
CE 875 L1
insure,
affirm that I have a s'C6m en ti consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'C6mpensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILOI Na qj2
ADORGe0 J
Q Certified copy Is hereby furnished euILG INE
w.DR ESS Lo cw Llrr I
Certified copy s filed with the county budding inspection OCALITY NEAREST
department CIE
ose ST
Date Applicant - Ew REar D18Te(CT r+� a TYPE PRD 99 ED Br
cwoee Sr �r.l�/ y,;/ CONST/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V U J/ V V
COMPENSATION INSURANCE o¢SCRIPrIon LOT NO ' BLOCK NA1 iowW wY STATE MAJOR Seco LOCAL
_---_ Noor OL•oca N_o _______._I c,wc L.l_—_ ___ _ _ _ __
(This section need not be completed of the work Involved TRACT NOW ON LOT USE zON¢ SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) Sxea or
l
I artilySIZE or LOT S .TING•TING BLD.
that in the performance of the work for which this _ o
permit Is Issued, I shall not employ any person in any manner OWNER _
so as to become subject to the Workers' Compensation Laws 17T Ir
AIL OCCUPANCY GROUP 0
Data Applicant ADDRESSif
w
NOTICE TO APPLICANT If, after making this Certificate of CIT. noL OCCUPANT LOAD a
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth
with Comply vo with such provisions or IhLS permit shall be
revo
deemed ked TRAILER USE ElP
GEOLOGY INSPECTION ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busy NO PERdIr ❑ (UST ITEMS BELOW) No Or EXITS
nes and Professions Code,and my Incense is in full force and
effect PARKING
w R K I Na
•PACE• RED D
License Number LIc Class LIMITED TIME USE
Contractor Date - .AT. DAT.
El D
I am exempt from the licensing requirements as I am a TRO.
licensed architect or a registered professional engineer SI E Or No of INSPECTOR
acting in my professional capacity (Section 7051, Bus- Ianno BLDG •TORIES
mess and Professions Code) FINAL APPROVAL
Lnc or Reg No Date PRESENT U•K Or BUILDING
I
HOME OWNER-BUILDER DECLARATION NO OF ExISTINa UILDINGS
ON LOT AND USE
I hereby affirm.that I am exempt from the Contractor's _
License Law for the following reason (Section 7031 5, Bust
Tress and Professions Code) NO PARKING - - 3 8 7 8 8 A
1, as owner of the property, sell do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section O # • •,5,. 88 S
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING • • • • • •
1 hereby affvm that there is a constmctnon lending agency 0 1. 15-88
for the performance of the work for which this permit is
Issued(Sec 3097,Cry C) _
Lender's Name
Pworo•eD MAX Oce
Lender's Address
I certify that I have read this application and state that the PERMIT FEE , BO -
above information is correct I agree to comply with all County ISSUANCE PEE '
ordinances and State laws relating to budding construction,
here yy'' authorize representatives of this County to enter TOTAL FEE O� O
on n dbove-ment d roper Per i pection purposes
jSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Cl Date