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Home My Public Portal About5403 TEMPLE CITY BLVD_Miscellaneous__ WOItKERS'COM.V"N5ADECLARATION 44 TION DECL76M4 r, - I CE 876 (180) MISCELLANEOUS APPLICATION I ft reh1 affirm that I 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 certdted copy thereof(See 3800 Lob C) Policy'10 Company FOR APPLICANT TO FILL IN Goowees 03 ❑ Ce'„fled copy a hereby furnished BUILDING / LOCALITY ❑ er ADDREea (.Ir rta copy flinspection with the county building specon NEAREST department m mens Louurr cwo SS ST Date_ Applicant NEAREST marwlnT no 0 ouP TYPE Pw SED BY CROSS ST ONST CERTIFICATE Or EXEMPTION FROM WORKERS LEcwL r ff COMPENSATION INSURANCE D¢SCRIPnon LOT NO eLocK '� _ r A, (c IRCLSI Srwra MwaoR as ND LOewL 1 no OF RLDCS (This section need not be completed d the work mvoWed TRACT ( 't now oN Lor USE ZONE 8weo AL CONDITIONS U by the permit is for one hundred dollars (5100) or less) /� EXISTING aliE OF LOT K !T O E%18TIX0 ¢LOO / I Q I certify that m the performance of the work for which this Q permit a Issued I shall not employ any person in any manner OWNER CA f U so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP - _ W ADDRESS qJ ' Cl. Date Applicant 2 NOTICE TO APPLICANT If after making this Certificate of carr C(� ,T,oL . Jh OCCUPANT LOAD Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forth AP LICATION FOR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE[] GEOLOGY INSPECTION C] No Spec Knowl ❑ deemed revoked ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am IlLensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOwI NO OF EXITS, 9 (commencing with Section 7000) of Division 3 of the Bust ness and Professions Code and my license is in full force and / / y effect a4 PA FKINO RCO D PROVIDED 9PAeaa License Number Lie Class LIMITED TIME USE Contractor Date GATS DAYS ❑ 1 To am exempt from the licensing requirements as 1 em I architect or”a registered professional engineer SIZE of No of INSPECTOR a acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES to NATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lie or Reg No Date CIV ING HOME OWNER BUILDER DLCLARATION I ON LoO No SNr AND aaD ..V BUILDINGS - R I hereby affirm that 1 am exempt from the Contractors # • • • • 3O License Law for the following reason (Section 7031 5 Busl , nese and Professions Code) NO PARCae FROV ID¢D 1 • S 8 Q 5 pKING a F-1PA I as owner of'the property will do the work and the _ _ structure is not Intended or offered for sale (Section • • • 8 Q 5 0 7044 Business and Professions Code) PROPOSED CASE OF BUILDING - 04, 1 6 -86 CONSTRUCTION LENDING AGENCY 1 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 Dec Lender s Address /Iw - PERMIT FEE r Np _ I certify that I have read this application and state that the above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to budding construction TOTAL FEE and hereby authorize representatives of this County to enter upon tp�above��yyentione pr perty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE (vial td 1 4-4 rQ 3/2 SI store of Permstlee � Date -