HomeMy Public PortalAbout5780 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION �'CIEMa711-845 aa M I SC E L LA N E O U A P P L I C AT[O N
85(I lice eby.affirm.that I have a certificate of consent to self f
insure. or a cq;tificate.of workers'Compensation Insurance,or I COUNTY OF LOS.ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.C.). "
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS ADO /fG�f A: `
Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS 5800 Tem��le Cit Blvd.
depaift ied enopy zs filed with the county building inspection CALITY Temple City B1. & Workman NgARCROSsT.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE CE'SSED BY
CROSS ST. Workman/ NE Corner D [! _� CONST.,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIGHWAY gTATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need .not be completed if the work involved TRACT NOW-ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF _
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
I o
permit is issued,I shall not employ any person in any manner OWNER C.
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP � -- o
Date Applicant. ADDRESS P'.O. Bo 480263 t3
cs
NOTICE TO APPLICANT: If, after making,this Certificate of CITY Los. Angeles, CA
TEL.
. (213) 930-1396 OCCUPANT LOAD
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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with.Section 7000) of Division 3 of the Busi- ❑ (LIST ITEMS BELOW NO. OF EXITS
ness and Professions Code,and my license is in full force and III
effect. REQ'D D PROVIDED
SPACES,
.�J
PARKINS,
License Number Lie. Class Temple City Funeral Home
LIMITED TIME USE .
Contractor Date. , DATE bATE
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF No. OF PROM. TO. INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES i SIGN URB
inessand Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING I 119^7-7-1
�y
HOME OWNER-BUILDER.DECLARATION NO. OR EXISTING BUILDINGS � ' NO FEE
• ON LOT AND USE
I hereby affirm that I am exempt from-the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
I, as ownerof the property, will do the work and the SPACES PROVIDED � �?e:`t � �:•� _��:1'_`
structure is not intended or offered for sale (Section r
7044,Business and Professions Code). v
CONSTRUCTION LENDING AGENCY PROPOSED USE OF 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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address I
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and he orize representatives of this County to enter TOTAL FEE
u o e ove- entioned property for inspectioi pulp
l /s!?� , ISEE REVERSE FOR EXPLANATORY LANGUAGE
of�
nature o ermittee Date
16