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HomeMy Public PortalAbout4505 TEMPLE CITY BLVD_Miscellaneous__ RKERSf COMPENSATION DECLARATION CE 875 (11 84) MISCELLANEOUS APPLICATION {� CE 876 LI 1here affirm that I have a certificate of consentSto'setf COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers Compensation Insurance,or a certified copy thereof(Sec' 3800,Lab C) Policy No Company FOR APPLICANT TO FI LL IN ¢UILOIN0 A j� �n e V .00Res. 'Y' Certified copy Is hereby furnished EUILOING SO I ty $ LOCALITY eM 1- wooR¢aS Certified Copy Is filed with the county building inspection Locw uTr r I NEAREST department 1Q/h4 CROSS ST Date Applicant NEAREST DISTRICT No our TYPE ie PRoceaa¢O EY CROSS ST (% f CONST CERTIFICATE OF EXEMPTION FROM WORKERS' L¢awL �I'1 a COMPENSATION INSURANCE o¢acRIPTION LOT n0 d 4 aLOCK _ ICA ae)NO OP STATE MAJOR SECOND LOCAL OLNO (Thea section need not be completed d the work Involved rawer �OZ � g' Now ory LOT I USE zoneaP¢owL CONDITIONS - by the permit a for one hundred dollars (S100) or less) CASE STING 1 certify that in the performance of the work for which this SIZE oP LOT 6100 exlanna BLDG permit is Issued, I shall not employ any person in any manner ONN¢R (�gtpenJ o U so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o wOOeeae -� Date Applicant Las r E3 NOTICE TO APPLICANT If, after making this Certificate of CITY rT-' 4 - 1600 OCCUPANT LOAD 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 provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked ❑ E] No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bust NO PERMIT E] (LIST ITEMS reww) No oP ¢xlre ness and Professions Code, and my license Is in full force and effect Pw . G ­Q6PAC¢a p O PROV1060 License Number LIc Class LIMITED TIME USE Contractor - Date O.T. O.T. I am exempt from the licensing requirements as I am a heensed architect or a registered professional engineer SIZE OF NO or INSPECTOR s acting in my professional capacity (Section 7051, Bus- EXISTING SLOG STORIES O� Sia rue¢ mess and Professions Code) FINAL APPROVAL LIc or Reg No Date PR¢SENT u E OP BUILD 8 _I HOME OWNER-BUILDER DECLARATION No OR EXISTING BUILDINGS , -I, ON LOT AND USE _ I hereby affirm that I am exempt from the Contractor's •T License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING El1, as owner of the property, will do the work and the SPACES PROVIDED ITEM= structure is not intended or offered for sale (Section AL 7044,Business and Professions Code) - _I}I —234 - 45 CONSTRUCTION LENDING AGENCY Pworoe s¢ OF BUILDINGCHECk ��4.� I hereby affum that there Is a construction lending agency I.HAN6E ,I_I) for the performance of the work for which this permit is issued(Sec 3097,Cm C) Lender s Name PR OPOa6D Mw% Dec JIIVrF'Jl�ll L,lot J''� Lender's Address i PERMIT FEE 1 AN n 1 IYi1:,f1 I artily that 1 have read this application and state that the above information Is correct I agree to comply with all County ISSUANCE PEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL PEE,,Q8 , upon the above mentioned pro pe for inspection eurposes / SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature of Permittee Date