HomeMy Public PortalAbout5819-5819 1/2 TEMPLE CITY BLVD_Miscellaneous__ ;- WORKERS'COMPENSATION DECLARATION CE 875(11-84) M ISCELLANEOU§ APPLICATION
I hereby affirm that I have a• certificate of consent to self COUNTY OF LOS ANGELES ; BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
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a.certified copy thereof(Sec.3800 Lab.C.).
�7 Com an rcirmt-r-S BUILDING /I f
PolicyNc��B' .I p y I FOR APPLICANT TO FILL IN ADDRESS % L-
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Certified copy is hereby furnished. I AU ILDINDRESCjB lq Z e C,t �1J LOCALITY C
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. I -- Q CA 1 A D CROSS ST.
Date Applicant I NEAREST i ISTItIC�`qip. �O-up
TYPE / PR SBD BY
CROSS ST. 1J iJ /,/V�plixVa'1 CONE
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ���1II
COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP {/ ) IDMW AY
No. /✓V� (CIRCLE) STATE MAJOR SECON LOCAL
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPE IAL CONDITIONS Ll
by the permit is'for one hundred dollars ($100) or less.) USE of 1
i
I certify that in the performance of. the work for which this SIZE OF LOT EXISTING BLDG. vV
o
l!
permit is issued,I shall not employ any person in any manner' IV OWNER I` C)ncwl er'
so as to become subject to the Workers' Compensation Laws. Q T OCCUPANCY GROUP.ADDRESS � -11 e •f 61� • �- CIE t;
O
Date Applicant TEL 2.� O I o_
NOTICE TO APPLICANT: If,after making this Certificate of CITY a No. ms —J-O9 �j ` OCCUPANT LOAD
Exemption, you should become subject to the Workers'' PPLICATION FOR 1 EXIT HARDWARE:
Compensation provisions•of the Labor Code,you must forth- i
with comply with such provisions oI this permit Shall be' TRAILER USE GEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi-, NO. OF EXITS
ness and Professions.Code,and my license is in full force and
PARKING
effect. SPACES REq'D D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
❑ 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 SIGN URE
inessand Professions Code). • FI!NAL APPROVAL
RESENT USE OF BUILDING OT-ti Gem
Lic.or Reg.No. Date V
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
usiness and Professions Code): NO. PARKING
I, as owner'of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section :0 6 6 1h C�
0 D D
7044,Business and Professions Code). 0 0 0 D D z
PROPOSED USE OF BUILDING O �C-� 0 3 0 9 8 7
CONSTRUCTION LENDING AGENCY .�
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. I '
Lender's.Address
I certify that I have read this application and state that the PERMIT FEE p0 I
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of th' County to enter TOTAL FEE ,00 i
lfpo he above-mentioned property for in ction purposes.
J � SEE REVERSE FOR EXPLANATORY LANGUAGE
/ 2 8�J ;
Signature of 1'e itt
Date
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