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