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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