HomeMy Public PortalAbout5843 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 875(2-80)
CE MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or I
a certified copy thereof(Sec.3800,Lab.C.) 'fl
Policy No. Company FOR APPLICANT TO FILL IN BuILD:NG J
PDD RESS @-
❑ Certified copy is hereby furnished. BUILDING O 2 / >C 421,
� ) 0 LOCALITY
❑ ADDRESS Q J Gc s•.V –
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY 7-E_)V p��" / CROSS ST.
�y
Date Applicant 'NEAREST a �-' DISTRICT NO.. GROUP TYPE PROC SSED BY
CROSS ST. LAS / Y NA.5 JDA - i/'I'O (/ � CONST. ,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL /J J (� V
COMPENSATION INSURANCE DESCRIPTION LOT NO. '1 / BLOCK MAP 'J HIGHWAY a
D'- No. �00/ (CIRCLE) STATE MAJOR SECOND LOCAL
/�r�h15 section need not be completed if the work involved NO. OF LOGS. USE ZONE SPECIAL CONDITIONS
�• P TRACT NOW ON LOT V
by the permit is for one hundred dollars (5100) or less.)
USE OF
SIZE OF LOT EXISTING BLDG. tY
certify that in the manof the work for which this I � O
permit is issued, I shall11 not not employ
loy any person in any manner � OWNER G..
so as to become subject to the Workers' Compensation Laws. MAIL / L OCCUPANCY GROUP ��� W
ADDRESS PO, to (/ I d
Date Applicant f C
NOTICE TO APPLICANT: If, after making this Certificate of L CITY J&-R?L ��7. i� Z85-2171 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPL 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 INSPECTION11 NO Spec. Knowi. ❑
deemed revoked. I Panic Devices El
CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT V (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 REQ'D PROVIDED
License Number Lic.Class ��JJ
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a I i
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). L FINAAPPROVAL1T\j,i�
'PRESENT USE OF BUILDING / Z_
Lic.or Reg.No. Date
terrAh. qo MF Fv�INf s��rVcs
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
I 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- –_926S1 A
ness and Professions Code): NO. PARKING
SPACES PROVIDED
Ell, as owner of the property, will do the work and the 0 0 0 0 8 8
structure is not intended or offered for sale (Section0 0 0 0 0 0 0 En
7044, Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY 01. 15'-82
�T �L Flo NE �0RN�S N JN6 S
I hereby affirm that there is a construction Ienlling agency 4, !J'
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 ISSUANCE FEE
ordinances and State laps relating to building construction,toenter
ter TOTAL FEE x JC'��
and ht2reby authorize representatives of this Count to enter
upo theve-m tiondoperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date