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Home My Public Portal About4522 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 76M444 M ISCELLANEOUS APPLICATION {� LI 1 hereby affirm.certithat I have a certificate of consent to self CE 875 (11 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certdiate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800, Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy Is hereby furnished BUILDING .DDR... LOCALITY Certified copy is filed with the county building inspection LOCALITYNKARUBT I department In I ill, CROSS IIT Date Applicant NEAREST DISTRICT No a ouv TYPE �� cH9a¢o BY CR090Lou) D O C07.oe CERTIFICATE OF EXEMPTION FROM WORKERS' Lc BY le OT a y COMPENSATION INSURANCE onSCRIPTIONLOT no BLOCK MAP - .1..w AY _ ..o Iu CL.l arwTe MAJOR ae=on° LOCAL NO OF BL°6II (This section need not be completed of the work involved TRACT HON ON LOT vow :One SPECIAL co nolrlonS by the permit is for one hundred dollars ($100) or less) UIIe OF OIZE OF LOT a%I.TING BLDG I certify that in the performance of the work for which the o permit is issued, I shall not employ any person many manner OWNER so as to become subject to the Workers' Compensation Laws MAOCCUPANCY OCCUPANCY GROUP �a o woDREII Date ApplicantI.i NOTICE TO APPLICANT If, after making this Certificate of Y CITY NOL OCCUPANT LOAD - Exemption, you should become subject to the Workers' APPLI ION F R EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be TRAILER UBEGEOLOGY INSPECTION deemed revoked ❑ E] No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter SAFETY P RMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Bust- NO or EXITS ness and Professions Code,and my license s in full force an effect PA Re I na r 4rAC6O REG D � PROVIDED Class I License Number Lnc - LIMITED TIMEPdfsE FEE Contractor Date DATA DAT. DI am exempt from the licensing requirements as I am a PRDN _ _ _ ,194 licensed architect or a registered professional engineer SIZE OF acting in my professional capacity (Section 7051, Bus- EXISTING BLDG IIrowlea °iOMA 1C, iness and Professions Code) I FINAL APPROVAL Lic or Reg No Date - Pw¢s¢nT u9e or BUILDING HOME OWNER-BUILDER DECLARATION NO Or EXISTING BUILDINGS Q 4 ON LOT AND YEE ,r I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031 5, Bun VVV nese and Professions Code) NO PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure Is not intended or offered for sale (Section - 7044,Business and Professions Code) ' CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING 1 hereby affsm that there is a constriction lending agency for the performance of the work for which this permits issued(Sec 3097,Cw C) , Lender's Name PROPOSED MAX OCC Lender's Address I certify that I have read this application and statePERMIT FEE that the I above information is correct I agree to comply with all County - ISSUANCE FEE ordinances and State laws relating to building construction, J1J and hereby authorize representatives of this County to enter TOTAL FEE a,S upon the ve-mentioned prope y far aspect on pu osess�� ✓ �y��'l 7j), ^SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu of Permittee pfi aam Jl/y WUKKLKS LUMYtrNSAIIVIN UtLLAKAIIUN 2000630M12/80 M1A7�.GLLHIVGVU.7 HI"t'LI<.HI IVIV 1 hereby pOln; that I gave a certificate of consent to self COUNTY OF LOS ANGELES - - BUILDING AND SAFETY DIVISION insure,or a certificate of Workers Compensation Insurance or a cdttified copy thereof (Sec 3800 Lab C) Policy No. Company =f FOR APPLICANT TO FILL INBUILaNG Fn� BBUILDING A 49 ADDPEBS N of Certified copy is hereby furnished yl �.t�' Vim+ LocALrrY Certified copy is filed with the county budding inspection CITYC. { ZIPn `n T department _l I l v NEAREST cROa9ST Date Applicant S12 OF LO NO OF BLOCS NOW ON LOT p Trp GR P TYPE I PROCESSED BY CON ST CERTIFICATE OF EXEMPTION FROM WORKERS DUI COMPENSATION INSURANCE TRACT BLOCK LOT No we N, wwr No ,cRCL[I STATE MAJOR SECOND LOCAL (This seetlon need not be completed If the wort( involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDr IONS by the permit is for one hundred dollars (SI00) or less.) v 1 certify that In the performance of the work for which this WNE 0Tt rl_� permit is Issued, I shall not employ anyrson m any manner so as to become subject to the Workers Compensation Laws A REss _ kA L4 5 `G,t e1 4-VQ OCCUPANCY GROUP FZA Nate Applicant - CrrZ^ IPG`,-1�S 1�/CYIICE TO APPLICANT If after making this Certificate aft ( 1 OCCUPANT LOAD of Exemption, you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Code you most forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed rRAILERUSE❑ GEOLOGY INSPECTION❑ revoked No Spec Knowl ❑ OCCUPANCY INSPECTION❑ Panic Domes ❑ LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ utsr ITEMS az I 9(commencing with Section 7000)of Division 3 of the Business NO or EXITS and Professions Code and my license is in full force and effect PARKING REO D D PPOVIDED D License Number Lie Class SPACES Contractor Date LIMITED TIME USE ❑` I am exempt from the licensing requirements as I am a FROM DATE TO DATE licensed architect or a registered professional engineer acting In my professional capacity(Section 7051 Business EizEOF NO OF INSPECTOR s and Professions Code) EXarTING BLDG STORIES SIG TrrRE Lie or Reg No Date PRESENT USE Or BUILDING FINAL APPROVAL w Qef1-tG,1 A HOME OWNER-BUILDER DECLARATION No or Exienwc BUILDINGS ON LOT AND USE '"Thereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 70315 Business and fhDfC5SI0r18 Code) I NO PARKING � ❑ I as owner of the property will do the work and ththe_ O SPACESPRVIDED structure Is not intended Or offered for sale(Section 7044)L PROPOSED USE OF BUILDING Business and Professions Code) lZ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 1 the'performance of the work for which this permit is issued 1(Sec 3097 Cot C) rYiOPOeEU MAX Dec. er s Name APPLicANT IRVNr1 Tcl No Lender's Address ADDRESS I certify that 1 have read this application and state that the above information Is correct I agree to comply with all County PERMIT Fee Pfl ordinances and State laws relating to budding construction and hereby authorize reepipritatives of this County to enter upon ISSUANCE FEE the above-menu r inspect purposes r 7 / TOTAL FEE �.d' g I )-O SEE REVERSE FOR EXPLANATORY LANGUAGE ignatur Permrtiee Date WORKERS COMPENSATION DECLARATION, ;�� z,90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �uwure.or a certificate of Worl en'Compensation Insurance,or ( � a certified copy thereof (Set, 3800 Lab.C) I - -' - Pohcy No Company FOR APPLICANT TO FILL IN BUILDING , BUILDING ADDRESS ADDRESS I e Certified copy is hereby furnished. X enY SZZ of BL-ArP LOCALITY D Certified copy Is filed mth the county budding Inspection zip NEAREttt department Fr C,I TY Coil- t7 80 a GST Date ' Applicant SIZ�r'O LOT NO OFLDGS NOW ON LOT DISTRICT NO GROUP TYPE rROCESSEO BY CERTIFICATE OF EXEMPTION FROM WORKERScoNer ( I COMPENSATION INSURANCE TRACT t4LOCK LOT ND M,e IKOMWAY No ICIKCLEI STATE MAJOR SECOND LOCAL (This section need not be completed If the work Involved ASSESSOR MAP BOON PAGE PARCELIISE ZONE SPECIAL CONDITIONS - by the permit is for one hundred dollars ($100) or less) I i I I certify that in the performance of the work for which this C �yv uwqe 7 LOI TEL Q I permit is Issued I shall not employ any person In any manner so as to become subject to the Workers Compensation Laws ADDRESS 0 gdx 12— 1,6 OCCUPANCY GROUP f Date Applicant CITY _ JUP /790 790 NOTICE TO APPLICANT If after making this Certificate OCCUPANT LOAD of Exemption you should become subject to the Workers 7 APP CATION FOR Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE ( comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSKCTION❑ No Spec Krowl ❑ revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Ij Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ IUSTITEMSBELOW, NO oP"ITS Name I I 9(commencing with Section 7000)of Division 3 of the Business �e o VH assnn.� a and Professions Code and my license Is In full force and effect A.ciNf AEn1T�JLT$TC(GY PARKING RED D PROVIDED O i License Number Lic. Class xACE9 t I Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as 1 am a FROM DATE TO DATE licensed architect or a registered professional engineer ( , actingg in my professional capacity(Section 7051 Business E®zEOFiG elm sTonlea INBIWVCATURE and Professions Code) Lic. or Reg. Na Date RLEBENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO or EXISnNG euILDINGs ON LAT AND USE I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 70315 Business and ( Professions Code) NO PARKING ❑ I as owner of the property will do the work and the SPACES PROVIDED structure is not intended or offered for sale(Section 7044 2 PROPOSED USE OF BUILDING Business and Professions Code) I I NA-ICfn elA- C i CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for #vwitt 0,. s the performance of the work for which this permit Is sued ( , (Sec. 3097,Civ C) 4>A-1'L/.s PROPOSED MAX Oce Lender s Name P LICANT r T7L No Under s Address ADDRESS J, 226-7y6 ( I certify that I have read this application and state that the 41M C'q"EZ41?5I, 6t+C& C t-&, CTI—?17FO above information is correct I agree to comply with all County PERMIT FEE ordinances and Stale laws relating to balding construction and hereby authonze representatives of this County to enter upon ISSUANCE FEE 1 I t the above-mentioned property for inspection purposes ( 2L TOTAL FCC e % S �` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Du