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Home My Public Portal About5313 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875 M ISCELLANEOUS APPLICATION CE 876 (11 841 1 hereby`a firmcert that 1 have n 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 •UILDINo wDDR¢vE ❑ Certified copy is hereby furnished raulLplNo ApDRH• LOCw LITY ElCertified copy Is filed with the county budding inspectionLOCALITY NEAREST department CROSS 8T Bete Applicant CROSS Sr mS��cr, c u2 �oN�� rRo eeD BY CROSS 8T IIJJ �iVV1l �. CERTIFICATE OF EXEMPTION FROM WORKERS' LEawL COMPENSATION INSURANCE p¢S CRIPTION Lor No ELOCX Ter (c6wc L.j STATE MAJOR SEC D LOCAL No or DI.DDe (This section need not be completed If the work involved TRACT — NO`r On LOT USK zone srlscuL conn mons by the permit is for one hundred dollars ($100) or less) _ ueEor a I certify that in the performance of the work for which this OIS¢ OF LOT ¢X 18 TING Loo permit Is Issued, I shall not employ any person in any manner OWNER v so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP- ADORB 8 Date Applicant NOTICE TO APPLICANT If, after making this Certificate of CITY rrioL _ OCCUPANT LOAD a Exemption, you should become subject to the+Workers Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USQ ❑ a LOGY INSPECTION ❑ No Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am hcensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS nELOW) 9 (commencing with Section 7000) of Division 3 of the Bust No OF RxITY ness and Professions Code,and my license is in full force and effect s.n c¢aG RRG o PR ovIDeD License Number Ln; Class LIMITED TIME USE Contractor Date pwTS DwrR I am exempt from the licensing requirements as I am a Tp licensed architect or a registered professional engineer SrzE or rNo or y I S ef�r R n acting in my professional Capacity (Section 7051, Bus- EXISTING BLDG ISTORIMS AA'' 2 ,p�rQ�IRQ mess and Professions Code) FINAL APPROVAL �/cy Lre or Reg No Date rR88QNT USE Or BUILDING f V • HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS 050 oN LOT AND USE • • • 8 rt 5 05 I hereby nffim that 1 am exempt from the Contractors CJ V. U License Law for the following reason (Section 7031 5, Busi- ness ust 7 2 3�,8 6 ness and Professions Code) NO PARKING 1, as owner of the property, will do the work and the arACES PROVIDED structure is not intended or offered for sale (Section _ 1, _ 7044,Business and Professions Code) - ' CONSTRUCTION LENDING AGENCY PROPOSED USE or BUILDING _ \ - I 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) Lender's Name PROPOSED MAX OCC Lender s Address I certify that I have read this application and state that the PERMIT FEE above information is correct 1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction, and hereby authorize representatives of this County to enter - TOTAL FEE upon the above-menti d property for in !cion purposes SEE SEE REVERSE FOR EXPLANATORY LANGUAGE _ Signature ermittee Date/