HomeMy Public PortalAbout5746-5748 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COl1MSAITON DECLARATION 7X761$4, M ISCELLANEOU APPLICATIONrim
I hereby affirm that I bet e a certificate of co self. coONTY OF LOS ANGEMS MUMG AND SAFELY DIVISION .
ioelre a certificate of Wor>cer0 Cpmpensatioa Insurance,
e,or-
s copy thereof Oec.3800,
Lb.C.).
Po1iLy.NorT_Campaa3y . , FOR APPLICANT TO FI LL IN w efeii .,J ' � '-
rl'CerFlfied copy iihce ILDINO ''
AYLITT ,
❑ OOtpy�swedfilththeODIiIItyb11{Id� j LOCALITY N ANENTdepartmen ,
DLteAppliciaal'' ROARER'! sTNICT NOr' G YP TTPi[ P�ROCEssED RY
i CROO ST. .r CpNs'[ r+•
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CERIICATS 017 EXEiPnON PRCPLWORKERS' ;j• L 96AL `
.COMEENSATION INS*gyp Amp DOSCRIPr1O1r Lor No. BLOCK i1�P HWKWAV
�p.��L���� V 7� 1 N�:OF NLOON. N jrrATM "JOE si COND LOCAL
\++W =tl0ll need_aot 1111 MMplst�ed N Ole WO* htvohrod��• TRACT now on Loy Y K ion. sPEC1AL CONOIrIONS
ty the permit Is-for one huadmd dollars (;100) or Ism) I• 1>�
IISK or o
mrft that in the of t>}•e WO$for Which tlEis alfa oP�w Ox or
BLDG.
permit is•issaed;I foot asaploy futw person in any=ch tbb owman .Ie t-i _l '•fe,r•'c:JV'r
sm ad do become pltllect to thaWorlurs'caompaasathiII Laws.•1 1L , f/6 a A• < < j OCCUPANCY GROUP'
.Date . Applicant rasa■ r!.^yrt
NOTICE TO APPLICANT: If.after , ' / TOL.r{ OCCUPANT LOAD o
making this Certffiate of•. arer . No.;t
Exam tba. YOU should bsmmq subject to the Workers' .APPLICATION FOR EXIT HARDWARE: ME
ME
Coai�edation Rrovidons of the Labor Coda yam must forth-
comWk with arch'providons or this .parmit.0ill. be i TRAILER USE❑ 15MOLOOT ANsPRa•{ION❑• No S7e0.Knowl.
LICENSED CONTRACTORS DECLARAT7,ON ocevPANaT iNEP�CIION[3 Panic d9{IIC6a �*• •4
I hereby affirm that I am Iicepsed under apr vWons of�p - i
9 (oomfinencing with Section 7000)Of D 3 Of 06 Tlnsl- SAFETY PERNee� (Liss IrEYs 7OLo!)
'fi0.OP EXITN 1
mess�Psoiesslons Coda;and mX Hennes id in toll force and �. A ik - - '
Effect. "• P NKIN6 ,REq'b =T PROVnixt
AGEE
License NuimbgrT�Lie'q. ` ' LIMITED AIME USE
L'OIIt1�CtDr, Daio .i 1 OATS: D�rrs
I tan wEe mpt from-the lieaa:ing raphements as•I am a �woRl roe r
lieemaed twZ"o'r a segleared profbedonal eaghm SIZE orn0.OP INSPECTOR•■
• acting in profesd and apadty (Section COSI.Bud- axis-rime BLDG. srowlKs slGnwrunE
ibes�SpdPFafbadahsCode). PREsenr Usk OR Nu(LDime. r NAt;APPROVALyj
;
Lio.orReg.No. Date!
HONX OWNER BUILDER DECLARATIONNO.OF KxirelNd iNuJLO1NGs, }
ON LOT AND use
I'hereby isffirm-that I abd,pxanipt,from the Contractor's e
1 ,
•I:iamsa Law fos the fdllowimg'reason.(Stiction 7031.5.Bud. .. �•�' �V'�l `{
nese and Prof edoms Code): NO.PARKING jr 't 1 (
- :l.-41 owner of the prope�, I will do the W4 and.the• .
Q'strmcim b not hltenl[ed or ofliesdd for sale (Section _
7044.Busimeie apd ProfealonsUode).
OONSTRUCTION•LENDING AGENCY PRoroseD use oP Nu1La1Ns
I heteby Billmm that time is a coartmction landing agency
,fbr thel performance of the-wwk fbr wbthis permit is t • . .
isered(Seo.3097.Cly.C.);
.Leader's Name I
PROPONNO NAX.OCC. 'I
Leader's Address
PERMITTER
'I c rtif)► that I have read this appiicatibn and state that the I '
•above information is oo, cL•I agree to oo�with all County I Is11YANca Pea `•
'ordinances and State laws kelatiag to conwhua ton. i
,ordinances
liaieby authorize representatives of this sty to eater TOTAL FEE
upo»j the•above�meathmed property for inspection purposes.
SU REVERSE'BOR.EXPLANATORY LANGUAGE. ( ,
Signature of Pamtes Date I