HomeMy Public PortalAbout4946 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION
I. CE 875 (11 e4) MISCELLANEOUS ApPLIC1TION
I
'
hereby-atfun icatt I have a s'CertificateCoen of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a cert irate of Workers'Compensation Insurance,or •
a certified copy thereof(Sec 3800,Lab C) ,
Policy No Company FOR APPLICANT TO FILL IN wU oRuss
euILOING
Certified copy is hereby furnished9y � G BL`/
ADOR Eas LOCALITY0 Certified Copy is filed with the county budding inspection LOCALITY NEAREST
department cwo.. Sr
Date A IrQnl NEAR Ler [ GISTR,c No our rrrC ROC Yeo Yr
pp CROSS ST LA 65A O 1 CONST l
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J
COMPENSATION INSURANCE DESCRIPTION Lor No BLOCK HIGHWAY STATE MAJOR Yeeono LOCAL
!TL No Or SLOGS -- - -Ic.w
-(This section need not be completed if-the work involved TRACT NOW ON LOT T u0 zone Srt C,AL CONDITIONS
by the permit is for one hundred dollars (SI00) or leu) _ u•E or �
I Certify that in the performance of the work for which this SIZE OF LOT ExISYIMG BLDG
permit B issued, I shall not employ any person many manner Olv..w 9I IF
FI v v
so as to become subject to the Workers Compensation Laws 1� CK
MAIL .� \�� OCCUPANCV.GROUP�
Date Applicant wD DRESS y � G j �_7, \` ` .+ i P \ Its
NOTICE TO APPLICANT If, after making this Certificate of CITY 6MAJ-16 �i l iJ TEL
g( Glc 7 3376 \% OCCUPANT LOAD O_
Exemption, you should become subject to the Workers' ti
z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provwons or this permit shall be TRAILER USE ❑ GZOLOGY INSPECTION ❑ No Spec Knowl
deemed revoked STIl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION dPanic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS-BELOW)
9 (Commencing with Section 7000) of Division 3 of the Bust- NO OF EXITS
ness and Professions Code,and my license a in full force and
effect egoKIN rw Cas RCD O PROVIDED
License Number eLic Class d � ��.J,� LIMITED TIME USE
Contractor Date "I""' OAT. AT.
I am exempt from the licensing requirements as I am a L•77 2JJ'441To
licensed architect or a registered professional engineer SIZE or No or INSPECTOR S
acting m my professional capacity (Section 7051, Bus- Exlen na eIDO STORIES SI ATURC
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date PRESENT wE or BUILDING__
HOME OWNER-BUILDER DECLARATION NO Or Cx,STING SUaLDINGS ;2,9 8 S 6 A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors a ' ' ' ' 30
License law for the following reason (Section 7031 5, Bust-
1
ness and Professions Code) NO PARKING • $0 5-
.2
I, as owner of the property, will the work and the • • • $0 S 0
structure is not intended or offered
SPACES PROVIDED d for rile (Section _
7044,Business and Professions Code) 1 ,1 04-86
CONSTRUCTION LENDING AGENCY PROPOSED U0E Or BUILDING �I q
I hereby affirm that there is a construction lending agency L-- Rkd L //0�.$ Ak65- i5vd-F A))
For the performance of the work for which this permit is
issued(Sec 3097,Civ C)
Lender's Name
PROPOSED MAX OCC
Lender's Address -
I certify that I have read this application and state that the PERMIT TEE
above Information is Correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building Construction, v
and hereby authorize re resentatives of this County to enter TOTAL FEE ej
upon th above-me o d property for inspection pu ows
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu01Armittee 6ate