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HomeMy Public PortalAbout5835 TEMPLE CITY BLVD_Miscellaneous__ i. "WORKERS'COMPENSATION DECLARATION CE 875(2-80) W SC E L LA N EO V APPLICATION I hereby affirm that I have a certificate of consent nc ,self:orl COUNTY OF LOS ANGELES BYJILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ❑ DDRESS / Certified copy is hereby furnished. BUDRESS cILDING n� OCALITY AD ❑ I Certified copy is filed with the county building inspection *EAREST �� department. O ALITY cky CROSS ST. 1 kVA Date Applicant EAREST 'DISTRICT NO. G OUP TYPE PROC �­­ NO. I CROSS ST. J v L� CONSTCERTIFICATE OF 1:XEMPTION FROMWORKERS' LEGAL L COMPENSATION INSURANCE DESCRIPTION L07 NO. BLOCK i.IAP HIGHWAY (CIRCLE) STATE MAJOR SEGOF SLOGS. O (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars (5100) or less.) use OF S ZE OF LOT EXISTING BLDG. I 0 I certify that in the performance of the work for which this; permit is issued, I shall not employ any person in any manner; OWNERnS U so as to become subject to the Workers'Compensation Laws., AIL a e�rF. I OCCUPANCY GROUPEal LU DDRESS d Date Applicant to NOTICE TO APPLICANT: If, after making this Certificate of rr G.� NO. ' •— D OCCUPANT LOAD � 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� i No Spec. Knowl. ❑ deemed revoked. Panic DBVICeS ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) I 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 FjARKING. effect. REQ'D E= PROVIDED SPACES License Number Lic.Class LIMITED TIME USE Contractor Date I DATE DATE ❑ PROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OFN0. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATUR iness and Professions Code). .400 PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date vu ` HOME OWNER-BUILDER DECLARATION NO. OF EXISTIKen DINGS ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's License Law for the follov�ing reason (Section 7031.5, Busi- ness and Professions Code): NO.PARKING ❑ FF I, as owner of the property, will do the work and the SPACES PROVIDED # S e structure is not intended or offered for sale (Section o 0 0 0 o O o 7044, Business and Professions Code). PROPOSED USE OF BUILDING � 07. 10-87 CONSTRUCTION LENDING AGENCY I 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. 1/ Lender's Address__ PERMIT FEE I certify that 1 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 Jbereby authorize representatives of this County to enter up eabove-mentioned prop ty for inspectio purses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date