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Home My Public Portal About5811-5811 1/2-5813 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444p g APPLICATION p CE 875(2-80) MISCELLANEOUS PPLICATION Ire affirm that I have certificate of consent self I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION irldu ore, or a certificate of Workers' rs'Compensation Insurance, e,or I a certified copy thereof(Sec.3800,Lab.C.) I Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS �/�, ❑ Certified copy is hereby furnished. uILDINGE CI I�_/f-I 0CALITY ❑ DDRESS ll rte_ Certified copy is filed with the county building inspectionNEAREST department. LOCALITY ' CROSS ST. Date Applicant NEAREST /ADISTRICT NO. GROUP TYPE / PROCESSED BY CROSS ST. CONST. V CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /_ j I D COMPENSATION INSURANCE DESCRIPTION LOT NO. (�j I/ BLOCK MAP �/ryry HIGHWAY NO. �i'V�, (CIRCLE) STATE MAJOR SECOND LOCAL tl I / NO. OFBLDGS. 0 (This section need not be completed if the work involved TRACT J NOW ON LOT USE ZONE I SPECIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less.) USE OF I SIZE OF LOT EXISTING BLDG. ^ Cc I certify that in the performance of the work for which this O permit is issued, I shall not employ any person in any mannerWNER Il Clldl — 1 W( w i5w-'D+D V so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W a DDRESS f O 1 Date Applicant NOTICE TO APPLICANT: If, after making this Certificate ofITY G Nio� 91&3 OCCUPANT LOAD � Exemption, you should become subject to the Workers' 1A PLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. ❑ deemed revoked. Panic DBVICBS ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- El ness and Professions Code, and my license is in full force and PARKING. effect. SPACES D REO' O PROVIDED D License Number Lic.Class ; LIMITED TIME USE Contractor Date DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer' SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- XISTING BLDG. STORIES SIGNATURE' iness and Professions Code). FINAL APPROVAL RESENT USE OF BUILDING /J i e II Lic.or Reg.No. Date G• V G r v i NO.OF EXIS HOME OWNER-BUILDER DECLARATION TING BUILDINGS 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- z 4 5 5 4 A ness and Professions Code SPACES PROVIDED NO. PARKING D ❑ I, as owner of the property, will do the work and the I structure is not intended or offered for sale (Section I # o 0 0 0 4 0 7044, Business and Professions Code). PROPOSED USE OF BUILDING ,1 / }4� I I O O O O O O O CONSTRUCTION LENDING AGENCY •Y �J t7 3.2 7—8 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.C.). Lender's Name PROPOSED MAX. OCC. 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 I ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE a d hereby authorize representatives of this County to enter , u on the above mention d roperty for inspection purposes. ; SEE REVERSE FOR EXPLANATORY LANGUAGE J Signature of Permittee Date I ; I ' WORKERS'COMPENSATION DECLARATION 76M444 I�C LA N EO U S APPLICATION I hereby affirm that I have a certificate of consent self CE 875 (2-80)I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or � a certified copy thereof(Sec.3800,Lab.C.) Policy No. Qompany FOR APPLICANTTO FILL IN (BUILDING 1 ADDRESS IQ ❑ 3 Al I Certified copy is hereby furnished.❑ UILDING ` GN U ` (LOCALITY ADDRESS CJS' Certified copy is filed with the county building inspection NEAREST department. LOCALITY Q_ �� . C� O+t' CROSS ST. Date Applicant. AREST ��a��`~ 1 [NOP TRICT NO. GROUP TYPE PROC SED BY ROSS ST. W�-�7 1. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK . HIGHWAY STATE MAJOR SECOND LOCAL } e"J (CIRCLE)NO. OF BLOGS. (This S0Ct10R need not be completed if the work involved TRACT NOW ONLOT ZONE SP CIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) I USE OF SIZE OF LOT EXISTING BLDG. t lX I certify that in the performance of the work for which this 6, � O permit is issued, I shall not employ any person in any manner LA61WNER so as to become subject to the Workers' Compensation Laws. IL ^[ �,. OCCUPANCY GROUP W ' ADDRESS rJg�j ` u VOW�/v Date Applicant ^ awl NOTICE TO APPLICANT: If, after making this Certificate of ITY G� No OCCUPANT LOAD Z Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. deemed revoked. ❑ ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter i SAFETY PERMIT ❑ (LIST ITEMS BELOW) No. OF EXITS ❑ 9 (commencing with Section 7000) of Division 3 of the Busi- fI. s and Professions Code, and my license is in full force and PARKING. ect. SPACES REO'D PROVIDEO ensee Number Lic.Class I LIMITED TIME USE Contractor Date b DATE DATE ROM: TO: ❑ I am exempt from the licensing requirements as I am a , licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 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 ` SPACES PROVIDED ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section u 7044,Business and Professions Code). I PROPOSED USE OF BUILDING ' CONSTRUCTION LENDING AGENCY I . I hereby affirm that thereis a construction lending agency . for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name i PROPOSED MAX. OCC. 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 FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter i upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I 14 Sign" tujy'�g of Permittee Date pCosCZZ h.I " X i