HomeMy Public PortalAbout4918 TEMPLE CITY BLVD_Miscellaneous__ RKERS COMPENSATION DECLARATION CE 8754"
(2 MISCELLANEOUS APPLICATION
1 hereby affirm that I hase a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
m1wre or a certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3800 Lab C)
Policy No CompanyFOA APPLICANT TO FILL IN Bu LD.No
woow¢se
❑ Certified copy,s hereby furnished --.LOIN. -
ADOR¢.. LOCALITY
Certified copy rs filed with the county budding inspection NEARS.r
department LOCALITY CROSS eT
Dale Applicant N-.wear
ewoee ST
CERTIIIC EXEMPTION FROM WORKERS LEGAL olarR:Kv a/yl��
pw CrYOrRe r
COMPENSATION INSURANCE OeacRirnory
PRo eO ¢r
Lor vo -LO-- NAr
Y
STATE Mwaoe ¢¢ o LOCAL a
� I o
(Thr- SQCtwn need not be completed if the Work involved OF -LOOS 0
TRACT NOM ON LOT ua¢ ZONE SPECIAL co NoiricNs U
by the permit Is for one hundred dollars ($I00) or less) N
uae orD�I
O.ZC OF LOT exISTITINa ¢LOO 11C`
I certify that in the performance of the work for which this e, p^^ 0
permit Is Issued I shall not employ any person ,n any manner OWNER
so as to become subject to the Workers Compensation Laws NAIL e' -�l���ya OCCUPANCY GROUP LU
AD DR¢sa �( �L 010 1 r
Date Applicant �y
OTICE TO APPLICANT If after making thin Certificate of CIT r Fria /N - ��/ OCCUPANT LOAD
Exemption you should become subject to the Workers APPLI ATION OR EXIT HARDWARE
Compensation provu,ons of the Labor Code you must forth
ilh comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION No Spec Knowl ❑
eemed revoked P
LiCLNSED CONTRACTORS DECLARATION occurwvcY IrvaP¢cnO. Panic Devices ❑
hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMITv (LIST ITEMS BELOW) NO or EXITS
(commencing with Section 7000) of Division 3 of the Bus,
ess and Professions Cade and my license ,s ,n full force and PARKING
fCCI REO O � ........ D
SPACES,cense Number Lic Class
LIMITED TIME USE
ntractor Date OATS GwrS
T.
1 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE or NO OF I.SPE.TOR'a
acting ,n my professional capacity (Section 7051 Bus- EXISTING -LOC STORI98 SIGNATUR9
mess and Professions Code) PRESENT USE or BUILDING FINAL APPROVAL
re or Reg No Date-
1
ale �v
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 fallowing reason (Section 7031 5 Busl
ness and Professions Code) No PARKING
SPACES PROVIOED
❑ 1, as owner of the property will do the work and the
structure is not intended or offered for sale (Section _
7044 Business and Professions Code) PROPOSED USE or BUILDING ;14759A
CONSTRUCTION LENDING AGENCY # S S e 30
I hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is • * 8050
issued (Sec 3097 Civ C)
Lender s Name PROPOSED MAX Dec
060 ° 85
Lender s Address PERMIT REE
1 certify that 1 have read this application and state that the ISSUANCE FEE
above information is correct I agree to comply with all County
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authorize represe at Ives of this County to enter o
up [he above mentioned erty for inspect pn�ur SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee (bate