HomeMy Public PortalAbout4829 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION ,
CE 875(11 84) MISCELLANEOUS APPLICATION JJJ'''777
CE 676 f�
I hereby affirm that 1 have a certificate of consent to sed 1 COUNTY OE LOS ANGELES; _ ✓, BUILDING AND SAFETY DIVISION IILJII
msuw,°or a certificate of Workers'Compensation Insurance,or �
a certified copy thereof(Sec 3800, Lab C) \" \;� . ��` �. �c'. ('.S\ s �� 1 _
Policy No Company FOR APPLICANT TO FILL IN \I DUILD INa Q
w Dawes O
Certified Copy Is hereby furnished _ iBUILCNo dp`Z q�' �+ - ( I\ 'fes', C
AD ORE 99 \'7 . V L. ALITr G
Certified Copy is fled with the county building inspectionLOCALIT I NEAREST department CROSS 9T
Date Apphcant NEAREST /•�yG� �� ,�. T � wl� �, \ V
D TT IC/��ryr/p PR es er
CR099 9T\ L�MAX I • (Jw• r LS rn K� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ✓� `J.J `+ 1 `. L ✓ V ✓
COMPENSATION INSURANCE UESC*IPT1ON,I LOT NO A eLOCKc F�sr1 r.or ;cowRC L..
_ N it STATE NwioR a cO LocwL
J ( 1 NO OF LOT OSE ZONE SP6 CIAL CONDITIONS
(This section need not be completed J the work involved rwwcTl �(A•¢;� ' rv0W ON Lor i
by the permit Is for one hundred dollars ($100) or less) ,
SIZE`or�LOT , �\I • Ex1¢9TONa OLDG y•.y '
I certify that in the pperformance of the work for which this _ o
permit is issued, I shall not employ any person in any manner OWNER MI(_ t Mrs -
so as to become subject to the Workers' Compensation Laws
MAIL OCCUPANCY GROUP o
AD OR 993 2,O I�(0
Date Applicant W
NOTICE TO APPLICANT If, after making this Certificate of CITY NOL SOs 29(. — 41q OCCUPANT LOAD
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Cade, you must forth-
with comply with such provisions or this permit shall be TRAILER USE ❑ G o Oav INSPECTION ❑ No Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIo ' Panic DevicesEl
I hereby affirm that 1 am licensed under provisions of Chapter SwF¢rr PERM (LIST ITEMS ea Low)
9 (commencing with Section 7000) of Division 3 of the Busy NO or EXITS
ness and Professions Code, and my license is in full force and (
effect Q..f I PA KING ovmEa
9rw KINCK. REO o PR
License Number Lie Class LIMITED TIME USE
Contractor Date —ut^ DATM DATE
❑ I am exempt from the licensing requirements as I am a KROM T.
licensed architect or a registered professional engineer Srz¢or No or INSPECTOR e
acting in my professional capacity (Section 7051, Bus- EXISTING SLOG 9roR1Ea 9IaNAT ¢
mess and Professions Code) FINAL APPROVAL
Lie or Reg No Date PRESENT use or eu uoina
HOME OWNER-BUILDER DECLARATION EX[STING eulLDirva9 x307 .N}
ON
ory LOT ANDo USE 1
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Bun TOTM 93 . 00
ness and Professions Code) NO PARKING //���iJr[�(({{// 1I�
SPACES PROVIDED 4r EV, 93.NI
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section _ l .UU
7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency 0000-0001 owl 6/90
for the performance of the work for which this permit is 2234 1 AM 7:31
issued(Sec 3097,Cry C)
Lender's Name
PROPOSED MAX OCC
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct I agree to comply with all Counry ISSUANCE FEE
ordinances and State laws relating to budding construction, O
and hereby autllorme representatives of this County to enter TOTAL FEE
�tlppli above- t`oi property for inspection pgu �Oseg
/YI /f 6 SEE REVERSE F R EXPLANATORY LANGUAGE
Signature of Pe ttee Date