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HomeMy Public PortalAbout5825 TEMPLE CITY BLVD_Miscellaneous__ . .. I WOR.KERS'tOMPENSATION'DECLARATION 76M4.4.4 IdYIS�.ELLANEOUS APPLICATION hereby affirm that I have certificate of consent to CE 875 (2-$0)self COUNTY OF LOS ANGELES t BUILDING AND SAFETY DIVISION insure, or a certificate.of�Norkars'Compensation Insurance,or a certified copy thefeaf(Sec.3800,Lab.C.) i Policy No. Company FOR APPLICANT TO FILL IN `BUILDING ❑ ADDRESS Certified copy is hereby furnished. uI40ING ❑ ADDRESS �UO( ,LOCALITY Certified copy is filed with the county building inspection r— 1NEAREST LOCALITY / /� department. [LP G CROSS ST. 'AR ST I .y� d• DISTRICT NO. GROUP TYPE PR ESSED BY Date Applicant CROSS ST. r aS /C fZY> CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ©ur ..� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK M.Av �y t11GNwwY 9IA7E MAJOR SECOND LOCAL } NO. V (CIRCLE) N.O. OF SLOGS. (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 ,/!jam/ 0 SIZE OF LOT EXISTING BLDG. .. . el, Q: I certify that In the performance bf the work for which this permit is issued, I shall not employ any person in any manner wNER f�(, lfC�j .[� 0 .so as to become subject to the Workers'Compensation Laws. MAIL � OCCUPANCY GROUP U • ADDRESS.O 6�1 /B C �""•� (L UJ Date Applicant M TEL. 0 "`clOCCUPANT LOAD NOTICE TO APPLICANT: If,.after makingthis.Certificate of• Iry l NO. w Exemption, you should become subject to the Workers' APPLICATION 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 D2VICe5 ❑ LICENSED CONTRACTORS DECLARATION i OCCUPANCY INSPECTION�I I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO.. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is,in full force,and PARKING. effect. SPACES REO'D PROVIDED .License Number Lic.Class LIMITED TIME USE ,Conttactol Date DATE DATE ' •V - ... FROM: TO: '[]..I ❑.,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 inessand ProfessionsCode). n FINAL APPROVAL 7 RESENT USE OF BUILDING �- Lic.or Reg.No. Date YY((VVLL NO.OF EXISTING BUILDINGS ' HOME OWNER-BUILDER DECLARATION ON LOT AND U.SE. 0 1 9 2 5 A I hereby affirm that- I am exempt from the Contract'or's License Law for the following reason (Section 703.1.5, Busi- 0 0 0 0 8 ness and Professions'Code):. I NO: PARKING SPACES PROVIDED I y , ❑ I, as owner of the property, will do the work and the t o r o 0 0 0 o eN a structure is not intended or offered for sale (Section 51 278.3 ' 7044,Business and Professions Code). OPOSED USE OF BUILDING /bc e. 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 • I PROPOSED MAX. OCG. Lender's Address ; PERMIT FEE �• I certify that I have read this application .and state that the I ISSUANCE FEE above information t correct.I agree tcomply with all County ,: ordinances and State laws relating to building construction, , and hereby authorize representatives of this County to enter TOTAL FEE, ` 00 ; upon above-me ion roper fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat of Permittee Date f