HomeMy Public PortalAbout5849 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATIONDECLARAT[ON �CE875(11-84) •MISCELLANEOUSAPPLICATION }
hereby affirm that I have a certificate of consent tself
insure, or a certificate of Workers'Compensation insurance,or
a certified copy thereof(Sec.3800,Lab.Q. z
Policy No. Company FOR APPLICANT TO FILL IN BUILDI �
ADDRENSSG q v- cs��f+ �G
J
Certified copy is hereby furnished. BUILDING di / may» CIT i Y LOCALITY 4=—.F T y
X}L ADDRESS O�-t
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. ]pC (,Q- Cl Z' �J .Ross sT. (4Z
Date Applicant t NEAREST �1 /J DIST T X10. GR P TYPE CESSBD BY
CROSS ST. �N�A /2 ' /�y CONSTef
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - •-- (/e - --
COMPENSATION INSURANCE - - DESCRIPTION Lor No: BLOCK NOP (C`RCLE) STATE MAJOR SECOND LOCAL
NO.OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT use Z NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of P
1 SIZE T • • EXISTI G B G. 14
I certify that in the performance of the work for which this °-
0
permit is issued,I shall not employ any person in any mannelkX' OWNER O 1 111
so as to become subject to the W rkers' Compensati .. Laws. MAIL n nC OCCUPANCY GROUP
. ADDRESS SIS � 7'7S�UAI9� /Z U
Date 11 Applicant �'i 1666 6 sr�✓b ✓r/�a rr` ZP I LL,
NOTICE TO APPLICANT: If,after making this Certificate of CITY LG Ct ITv0" -QTS--o OCCUPANT LOAD 0-
Exemption,
Exemption, you ihould 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 ElNo Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
❑
1 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 anX
effect. Name of business PARKING REq'D PROVIDED
�
License Number Lic. Class < -.T SPACES[
LIMITED TIME USE
Contractor Date DATE DATE
0 1 am exempt from the licensing requirements as I am a PROM. TD.
licensed architect or a registered professional engineer SIZE OF No.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. X� STORIES / sl wTuwe
iness and Professions Code). FINAL APPROVAL.
Lic.or Reg.No. Date PRESENT USE OR BUILDING IIOMC.OWNER-Bl11LDER DECLARATION NO. OF RXISTING BUILDINGS pON LOT AND USE �iojl
I hereby affirm that I am exempt from the Contractor'sQ�.C���y�,�l 5,�VAC-., ,006--X-r4-f44A9^4-;r
License Law for the following reason (Section 7031.5, Busi- 1. •/1 ✓1�
ness and Professions Code): NO. PARKING
SPACES PROVIDED
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency ! Ctg L 6:97-9T6 Di T/C4--
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX.OCC. 6• Lender's Address
I certify that I have read this application and state that the PERMIT FEE 25.00i
above information is correct.I agree to comply with all County ISSUANCE FEE I ''
ordinances and State laws relating to building construction, i 1
and hereby authorize representatives of this County to enter TOTAL FEE 25.00 r
upon the bove-me i ed property for inspection purposes.
XX-•c� r XX SEE REVERSE FOR EXPLANATORY LANGUAGE a
Signature of Permittee Date ; rig