HomeMy Public PortalAbout5032 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875
I CE 878 -(11 84) MISCELLANEOUS APPLICATION
1 hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers Compensation Insurance,or
a certified copy thereof(Sec 3800, Lab C)
Policy No Company _ FOR APPLICANT TO FILL IN BUILDING
A
DDRene
Certified copy is hereby furnished BUILDING
ADDRESS d 2 L CjHjtAV0. LOCALITY
Certified copy is fled with the county budding inspection LOCALITY Ps.E C'1'f4A-jrTIYN9ARffST
department CR o¢S ST -
Date Applicant CROSS ST EM EG,rL-/ �wo DISTRICT CON • oc a BY
CROSS ST T
CERTIFICATE OF EXEMPTION FROM WORKERS' LE _L
COMPENSATION INSURANCE o¢QCRIPTION LOT No �J. DLocK-
NO '1O DLxI STATE Mw R CAL
NO OF BL 9
(Thu section need not be completed if the work involved TRACT NON ON LorT USE zone SPEeIwL eo nDlTlo na
by the permit is for one hundred dollars ($100) or less) r us¢ Or
I certify that in the performance of the work for which this SIZE of Lor exlSnna BLDG
permit is issued, I shall not employ any person many manner ONNaw i — y
So as to become subject to the Workers' Compensation Laws M^IL ,1 pp OCCUPANCY GROUP o
Date Applicant ADDRESS Q 'j. N• Cil � e' ffi
W
NOTICE TO APPLICANT If, after making this Certificate of CITY C I M U— woLvP
—S$3 OCCUPANT LOAD o_
Exemption, you should become subject to the workers' z
Compensation pruvinons of the Labor Code, you must forth APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be
deemed revoked TRAILER USE ❑ GEOLOGY INaPeerloN ❑ No$pBC KnOWI
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of ChapterSAFETY PERMIT LIST ITEMS OELOw O
9 (commencing with Section 7000) of Division 3 of the Bust ❑ ( )
NO of EXITS
ness and Professions Code,and my license is in full force and
effect PARKING
SPACES Rep D PROVIDED
License Number Lic Class I
7r—-2 LIMITED TIME USE
Contractor Date OATS OATS
I am exempt from the licensing requirements as 1 am a TO
licensed architect or a registered professional engineer SIZE of No of I are roR S
acting in my professional capacity (Section 7051, Bus-
EXISTING BLDG STORIES a TUwE
mess and Professions Code) FINAL APPROVAL 1
Lic or Reg No Date PRESENT USE OF BUILDING �� `
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS 30
ON Lor Axle,
I hereby affirm that I am exempt from the Contractor's - ANT3
License Law for the following reason (Section 7031 5, Bust J�i.07, t 9J.0�
ness and Professions Code) NO PARKING ;
I, as owner of the property, will PROVIDEDl da the cork and the _ 11
jTQs
structure is not intended or offered for sale (Section _ I TOTAL1 '93_ ��s
7044,Business and Professions Code) -,, --� ` \'
PROPOSED USE OF BUILDING J ))
CONSTRUCTION LENDING AGENCY v 'SFfCY�Cst; i 93.00I hereby affirm that there is a construction lending agency Y f
for the performance of the work for which this permit is , I J ! IC C 1 •�
issued(Sec 3097,Cry C)
Lender s Name r1�I
O • PROPOSED MAX OCC 1 ; ` 1 IWLN Ml I 5/1XW1
Lender's Address � � \ �'}� I �i`y a ,l
PERMIT Ffifi O oV .1\� ` 0730 i• 1 I'111 2.20
I certify that 1 have read this application and state that the r � t` '
above information is correct I agree to comply with all County Issuance FEE A �N,
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter TOTAL Fee
upon the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
S ture of Permittee Date