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Home My Public Portal About4812 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION 76M444 MISCELLANEOUS APPLICATION {� L1 I hereby a that I have a certificate of consent to self CE 875 (11 84)COUNTY OF LOS ANGELES . " BUILDING AND SAFETY DIVISION Cert Insure, of a certificn[e of Workers Compensation Insurance,or - a certified copy thereof(Sec 3800,Lab C) (f O/ Policy No Company FOR APPLICANT TO FILL IN weUILOI NO o oR¢ss 7✓ ✓t` Certified copy is hereby furnished BuILDINO �� •— LOCALITY wv DR¢ae (� ef Certified copy u filed with the county budding inspection LOCALIY NEAREST department CROSS ST Date Applrpnt NEAR, T DISTRICT No 6 OU• rYea R HBBaO BY CROwa ST O' CONST. / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a V COMPENSATION INSURANCE .ESCRIPT"N LOT No BLOC. ..P HIGHWAY No (cIRCLwI STATE MAJOR SECOND LOCAL NO OF SLOGS - ' (Thu section need not be completed if the work invoWed rwwcT NOW ON Lor USE zone sPanwL CONDITIONS by the permit is for one hundred dollars (f100) or less) Uwe or I certify that m the performance of the work for which this sea OF Lor HxIErlNa eLoo 'p� o permit is iswed, I shall not employ any person in any manner OWNER A cO SO as to become subject to the Workers' Compensation Laws MwIL OCCUPANCY GROUP �E o wvDReae Date Apphcant LU.] NOTICE TO APPLICANT If, after making this Certificate of elrr - TEL OCCUPANT LOAD Exemption, you should become subject to the \Yorkers' Compensation provmons of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY Ina Pa CTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the BusF SAFETY PERMIT E] (LIST ITEMS BELOW) NO Or axITE ness and Professions Code,and my license is in full force and �M 0-P- 2_ „- � effect ,ell1'}� Pq RR'NG w¢O D PR ovID ED wrwc¢s License Number Lic Class LIMITED TIME USE Contractor Date I DwTw Dw Tw ❑ I am exempt from the licensing requirements as,l am a .o Incensed architect or a registered professional engineer SIZE Or NO or IN EP¢croR w acting in my professional capacity (Section 7051, Bus- EXISTING eLoo STORIES q SIGNATuwE mess and Professions Code) _ I I FINAL APPROVAL q Llc or Reg No Date PR Pae NT uws or eulL // (_ HOME OWNER-BUILDER DECLARATION NO or EXISTING BUILDINGS - O `17 r_t FEL_ ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- tress and Professions Code) NO PARKING 1, m owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section L ,_ 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PRoroeeo uw or BUILDING 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is ugg issued(Sec 3097,Civ C) Lender's Name I PROPOSED MAX Dec Lender's Address - I certify that I have reNd this application and state that the PERMIT FEE above inWand is co ct I agree to comply with all County ISSUANCE PEE ordinanate 1 s relating to budding construction, and herenz p esentatwes f this County o ter TOTAL FEE upo then property nnspecuo p o s SEE REVERSE FOR EXPLANATORY LANGUAGE or Signatur of Permittee D e WORKERS COMPENSATION DECLARATION CE 876 (1 801 MISCELLANEOUS APPLICATION CE 876 LJ I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lib C) Policy No Company FOR APPLICANT TO FILL IN BUILDING i! ADDRESS Y Certified copy Is hereby furnished BUILDIrva wDOR-¢a CH ty NE R LITY Certified copy a filed with the county building inspection NEAREST department LOCALITY rr�� City, NEr `(A eIIOSS ¢T Date Applicant rte AReaT L Azusa D^^, OlarRler No OR P TVP PRO ea¢D,Dr C.OSS 8T Road CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NO OP DLODB No pIO/ (cinu¢) STATE MAJOR SECOND LOCAL a (Thu section need not be,completed if the work NVONed TRACT NOW ON LOT USE SONE EP ECIgL CONDITIONS O by the permit a for one hundred dollars ($100) or less) U 109E OF 1 cend that In the 512E OF LILT EXISTING BLDG (� y performance of the work for which this cc permit Is Issued I shall not employ any person In any manner OWNER azvC -rf� U so as to become subject to the Workers Compensation Laws MAIL OCCUPNY GOUP ACR wD DREa. ~ d Date Applicant TEL to NOTICE TO APPLICANT If after making this Certificate of /K .ITT , NO OCCUPANT LOAD � Z 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 ❑ ❑ NO Spec KnOWI ❑ Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INsr¢CTton I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ )LIST ITEMS BELOW) NO OF Ex ITS 9 (commencing with Section 7000)of Division 3 of the Bust nes and Professions Code and my license Is In full force and - effect PARKIN e RED O O rROVIDED EAR IN KS License Number Lie Class LIMITED TIME USE Contractor Date owre D.r¢ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR S acting In my professional capacity (Section 7051 Bus EXISTING BLDG STORI¢S SIGNAru RE mess and Professions Code) FINAL APPROVAL � PRESENT VSE OF BUILDING Lie or Reg No Date HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 BInn ness and Profusions Code) NO PARKING SPACES PROVIDED 1, as owner of the property will do the work and the 1 8 7.6 A structure Is not Intended or offered for sale (Section y - 7044 Business and Professions Code) PROPOSED U5E OF BUILDING rl 8 8 CONSTRUCTION LLNDING AGLNCY t I hereby affirm that there Is a conslruLtion lending agenLy for the performance of the work for which this permit Is I '1 0 6—8 1 issued(Sec 3097 Civ C) Lenders Name PROPOSED MAX OCC / Lender s Address PERMIT FEE I certify that I have read this application and state that the above Information D correct 1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building constru Ltion TOTAL FEE an J, ereby author representatives of this County t enter W-2 CzzT U the above toned rope [y f r mspec[I reuses SEE REVERSE FOR EXPLANATORY LA AGE 1 X Signal re of Permittee D e 1 WORKERS COMPENSATION DECLARATION CE 875 11 t 841 M ISCELeANEOUS APPLICATION CE ]fi I I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES _BUILDING AND SAFETY DIVISION te J insure, or a certificaof Workers Compensation Insurance or w1-1 a certified cop; thereof(Sec 3600 Lab C) - — �"�I Policy No Company — FOR APPLICANT TO FILL IN auiLo�na y /r2-- wOORiaa Certified copv is hereby furnished X wILOING LOCALITY woDR¢Sa 1 Certified copy u filed with the county building inspection LOCALITY -- - —� — — —' NEAREST department CAA e7lien CROSS By Date Applicant NEAREST 1 GYPS PLLw GROUP Qs[ED BY GROSS ST wmTO G CERTIFICATE EXEMPTION FRO\ VORKERS / ON2J& COMPENSATION INSURANCE or no BLocK 1GHRA IC,NCL[I STAT[ MAJOR SECOND LOCAL NO Or [LOOS (This section need not be completed If the work involved TwACT NOW ON OT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (S 100) or less) uSE 1 arzE or LOT Q I artily that in the performance of the Mork for which this — permit is issued I shall not employ any person many manner X OWNER ED as to become subject ,o the Workers' Compensation Laws MCCCUPANCY GROUP L woAILoRQaS SIG — 1 Date Applicant = TEL NOTICE TO APPLIC\NT If, after making this Certificate of CITY o � 'Q OCCUPANT LOAD -- Exemption you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE — Compensation provisions of the Labor Code }ou must forth- 1 with comply with such pmsuions or this permit shall be TRAILaR USEGEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY Ina r¢cnon Panic Devices _ I hereby affirm that I am Licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 1 9 (commencing with Seaton 7000) of Division 3 of the Busr NO OF EXITS ness and Professions Code and my license is in full force and effectES Fw RRING REDO rROV10 EO SPAC License Number Lie Class LIMITED TIME USE Contractor Date OATSTO OAP[ I El 1 am exempt from the licensing requirements as 1 am a { m 1 licensed archrtec- or a registered professional engineer SIZE OF No or INSPEcrow a z acting in ml professorial capacity (Section 7051 Bus- NISTIN. FLOG srowl¢a alG nwrua[ m mess and Professions Code) o PRESENT USi OF BUILDING j FINAL APPROVAL 92�� U Lie or Reg No Date X ) / HOME OWNER-BUILDER DECLARATION NO Or EXISTING BUILDINGS ON LOT ANo USX / 1 hereby affirm that I am exempt from the Contractor s i /r 1 License Law for the following reason (Section 70315, Bus- ness and Professions Code) NO PARKING 1, as owner of the propertv will do the work and the aPAcb rw ovlo EG / structure is not intended or offered for sale (Section j 7044,Business and Professions Code) / h' CONSTRUCTION LENDING AGENCY g PROPOSED USE of ¢UILOING / I hereby affirm that there is a construction lending agency i for the performance of the work for which this permit Is issued(Sec 3097,Cry C) I Lender s Name cm z PROPOSAO MAX OCC cm) i 1' Lender s Address / 8 I� 1 PERMIT FEE u�� 4 I I Certify that I have read this application and state that the / q above mformation is correct I agree to Comply with all County { ISSUANCE FEE ✓ g orduunces and State laws relating to budding construction i 1 and hereby authorize representatives of this County to enter TOTAL. FEE 25,00the hehe abOov or�antioned p perty for nspect�on purposes SEE REVERSE FOR EXPLANATORY L GUAGE � , m Signature of Permrttte Date P 70 70