HomeMy Public PortalAbout5442 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION
CE 875 I11 e4) MISCELLANEOUS APPLICATION {�
CE 875 LI
1 hereby affirm that 1 have a certof consent to ser
Insure, OF LOS ANGELES BUILDING AND SAFETY DIVISION
slre, or a cecertdipte of Workers CompCompensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO F I LL I N DUILDINo
wDDRees
Certified copy is hereby furnished BUILDING �� , Gjv�
A..... 5fo3 LOCALITY �L
0 department
copy is filed with the county budding inspection LOCALITY TG/h /G NE^REOT
pa IPG Cf� Cw038 8T
Date Applicant NBARCST 01-lk4 DISTRICT/NO Oggq 011ljjj��� TYeB PROCESSED RY
CR066 8T Pr ioa i( CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL r
COMPENSATION INSURANCE DESCRIPTION Lor no JP BLwRRwY
Boa STATE MAJOR SECOND LOCwL
NO OF L.G.DDaS
(Thu Section
erm need not be completed ll the work involvedless)
TRACT Now F Lor uaE zone SPeuwL cowOlnowe \
by the perms[ u for one hundred dollars (5100) or less) - u31 of
SIZE OF LOT Qx .TINo SLOG
I artily that in the performance of the work for which this Ave l7— y o26 � -
permit is issued, I shag not employ an) person many manner OWNER /V/ /'/Ac%/r/JSON
so as to become subject to the Workers Compensation Laws /�/ OCCUPANCY GROUP z
Date /O —90Applicant w" --^ ll/ �T--`.J
MAIL ESS sWl 0E T i fE w �/��s!��' W
NOTICE TO APPLICANT If, after making this Certificate of CITY IFS/ HaL B/�jZr177�aJ� OCCUPANT LOAD o_
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code,you must forth- APPLI ATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be
deemed revoked TRAILER USE GEOLOGY INSPECTION NO Spec KrioWl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITBMa DBLOW)
9 (commencing with Section 7000) of Division 3 of the Bust ND OF EXITS
ness and Professions Code,and my license is in full force and o7
effect / G 71,11 -s Pw RKIN6 REG O PROVIDED
!PACES
License Number -S Lie Class G— iC 7 5 T .✓G L sq
Contractor ate �0-/o-9d DATLIMITED TIME USE DA..
E] I am exempt from the Incensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO OF INSICCTCAS
acting in my professional capacity (Section 7051, Bus- ZX.ATINA BLDG !TORIES s'a..T
mess and Professions Code) FINAL APPROVAL
Lie or Reg No Date PRESENT u!e ov euILDlna
HOME OWNER-BUILDER DECLARATION NO OF eXISTING BUILDINGS �O
ON LOT ANO USE
I hereby affirm that I am exempt from the Contractors At Cj•*
License Law for the following reason (Section 7031 5, Bust '173,37 93.00
ne and Professions Code) _ IPA C88 OV NO PARKING
FR IOQD
1, as owner of the property, will do the work/and the 1 ITEIIS
structure u not intended or offered for sale (Section _ TOTAL 9J 007044,Business and Professions Code) ` �/
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK, 9„COCl
I hereby affirm that there is a construction lending agency CHANGE .03
for the performance of the work for which this permit is -
usued(Sec 3097,Civ C)
Lender's Name
PROPOSED MAX Occ 00101I-0001 10,'10/9j
Lender's Address PERMIT F PIK 3216 1 AM 7:35
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 /5 —
ordinances and State laws relating to budding construction,
and hereby authorize representatives of thu County to enter TOTAL REE
upon abo ment and property for mspecnon purpoxs
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatur f Pe ee Date ,