HomeMy Public PortalAbout5537 TEMPLE CITY BLVD_Miscellaneous__ WORKE+IS'COMPENSATION DECLARATION 76M444 IMISCELLANEOUS APPLICATION
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I hereby a rtn that 1 have a ceompte of consent to self CE 875(11 84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a Certificate C
rate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APP LICANT TO FI LL I N BUORENG - 45-
wDDaa
Certified copy Is hereby furmshedBU uvrrve rS3 C CI
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s
Certified copy Is Filed with the county budding inspection wvOREea J 1 LOLOCALITY NEwR e•r
department �, C 1- CROSS BT
Date Applicant NEw REEr DleTryrcr awo UP TYPE PRo •SED By
cwo•8 er n I Y l�.�A `'� con
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L VVV
COMPENSATION INSURANCE De•eR vnoN Lor No CLOCK
BOP Icrn Cr.•) STATE MAJOR •E ND LOCAL '
NO OP BLODB
(fllu section need not be completed If the Work InVOtVed TRACT NOW ON LOT U86 SONEErQCrwL CONDITIONS
by the permit Is for one hundred dollars ($100) or less) arse or LOT ¢UEEslenrva Or
BLDG i
I mrtify that in the performance of the work for which this o
permit is Issued, I shall not employ my person many mannerOWNER v
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o
Date Apphcant wv SPR see 7 b I V w
NOTICE TO APPLICANT If, after making this Certificate of CITY Q
TEL
_b OCCUPANT LOAD H
Exemptmn, 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
deemed revoked TRAILER USE E:] GEOLOGY rrvePQeTION ❑ NO Spec KnOWIEl
LICENSED CONTRACTORS DECLARATION OCOUPANcx INSPECTION�" Panic Devices
I hereby affirm that I am licensed under provisions of Chapter ewrery PERMIT ❑ (LIST ITEMS BELOW)
9 (comrrrencmg with Section 7000) of Division 3 of the Buss- NO Or Exrra
ness and Professions Code, and my license is m full force and
effect 1'� SPARING REO D D rROVrD ED D
BrACH9
License Number Lrc Class
LIMITED TIME USE
Contractor Dale OAT• OAT•
ff
I am exempt from the registered
requirements as I am a ' �Qi M r
licensed architect os fl registered professional engineer ars oP NO or I SIGNATURE S
acting m my professional capacity (Section 7051, Bus- exr9Trrva BLDG arowl¢a ErorvwruwH
mess and Professions Code) - FINAL APPROVAL
Lrc or Reg NO Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO oP ISTING BUIL rN 9
A
ON ,
I hereby affirm that I am exempt from the Contractor's AND ue b 4 6 9A
License Law for the following reason (Section 7031 5, Busr
ness and Professions Code) No P ! # • • • • 3
1, as owner of the property, will do the work and the aP w IDHD r
structure is not intended or offered for sale (Section I r+ �, -i ^`�+`\'I-- 8 Q 5
7044,Business and Professions Code) .4 t
• • 5
CONSTRUCTION LENDING AGENCY TRO/0 v SPE Or _ - ,�,:• 8 Q 5 0 v
1 hereby affirm that there Is a constmction lending agen ,0,20,5'8 7
for the performance of the work for which this permit +y
Rued(Sec 3097,Cw C) r ,...�
Lender's Name
PROPOSED MAX Dec
Lender's Address ,
PERMIT FEE
I certify that I have read this application and state that the
above information is correct I agree to comply with all County ISSUANCE PEE
ordinances and State laws relating to budding construction, _
and hereby authorize representatives of this County to enter TorAL FEE
upon the above-mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date