HomeMy Public PortalAbout5011 TEMPLE CITY BLVD_Miscellaneous__ ` WORKERS COMPENSATION DECLARATION CE 875444
(2 MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Lj
insure or a certificate of Workers Compensation Insurance or
a cev10ed copy thereof(Sec 3800 Lob C)
Pollc) No Company FOR APPLICANT TO FILL IN BUILDING /
ADDRESS
❑ Certified copy Is hereby furnished BUILDING / Locwury
ADD 00...¢H.
❑
Certified copy Is filed with the county budding Inspection NEwflesr
department LOCALITY elroeE Hr
Date Applicant NEAREST DISTRICT NO aRouP Tr Pe PRoe¢ eD BY
CROSS ST O BONS,
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
D¢SCRI PTION LOT NO BLOCK IL
COMPENSATION INSURANCE MAP jcln cAiil STATE MAJOR EEeo LOCAL a
rvO OF 8LOGH O
(This section need not be Completed if the work involved TRACT `— NOW ON LOT I GHQ zo NH aP QCIAL CONOITIOMe U
by the permit IS for one hundred dollars (S 100) or less) uee aF �- 1
I certifythat In the SIZE of Lor QxlanNo BLDG 2
performance of the work for which this O
permit Is Issued, I shall not employ any person In any manner OWNER
so as to become subject to the Workers Compensation Laws HAIL ' L i OCCUPANCY GROUP L W
ABBE... GM - ' a
Date Applicant N
NOTICE TO APPLICANT If after making this Certificate of CITY oL IR ?
1 OCCUPANT LOAD
Exemption you should become subject to the Workers gppLl ATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth - C
with comply with such provisions or this permit shall be TRAILER USE C] GEOLOGY INSPECTION
deemed revoked ❑ NO pPPiC KnOWI ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices ❑
1 hereby affirm that I am licensed under promions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) No OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busl
ness and Profesvons Code and my license Is In full force and �-6zyr - PARKING effect REGD PROVIDED
If
EPwCQE
License Number LIc Class
LIMITED TIME USE
Contractor Date - Dwrg DATE
❑ To
I em exempt from the register requirements as I em n
ctini architect or a registered professional engineer EaE of ZOO 5 No of INSPECTOR E
acting
m my professional capacity, (Section 7051 Bus- exlan NG elDa . HToflI¢H Sr—NATURE
Inns and Professions Code)
PRESENT USE OF BUILDING FINAL APPROVALu �� ✓
1 Ic or Reg No Date—
HOME
ate HOME OWNER BUILDER DECLARATION NO OF QxISTING BUILDINGS
ON LOT ANO USG
1 hereby affirm that 1 em exempt from the Contractors
82284A
License Law for the following reason (Section 7031 5 Bmi # e • e • 30
ness and Professions Code) ND PARKING
SPACES PRovID9. 3 1 • e 8 Q 5 0
_
❑ I as owner of the property well [ work and the e e e 8 0 5 0 6
structure Is not intended or offered
for for sale (Section •
7044 Business and Professions Code) PROPOSED USE OF BUILDING 6& -TGNS err! 0 61 9—8 5
CONSTRUCTION LLNDING AGENCY 6 r `
hereby affirm that there Is a construction lending agency
for the performance of,the work for which this permit Is
Issued(Sec 3097 Civ C )
It
Lender s Name
PROPOSED MAX OCC
Lender's Addressa
PERMIT FEE e
I certify that I have read this application and state that the
above Information Is correct I agree to comply with all County Issu ANCE FEE S i„
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authonre representatives of this County to enter
upon the ve mentio roDerty for mspel��(wO urp Ms SEE REVERSE FOR EXPLANATORY LANGUAGE
�gnature o ermrtteeermrttee lV.Daa(atte SS//r