HomeMy Public PortalAbout5853 TEMPLE CITY BLVD_Miscellaneous__ A CQ,QKERS'COMPENSATION DECLARATION 7.6M444 .
CE 875 (2.80) M ISCELLANEO . S APPLICATION
Ihyrbby affirm that I have a certificate of•consent to self COUNTY OF LOS ANGELES J'BUILDINGIAND SAFETY.DIVISIONinsure,or a certificate of Workers'Compensation Insurance,or
a certified copy theregf Sec.38001 L Ib.C.) /� u�q
Pol OOS mpany /'�-/L�7f�� FOR APPLICANT TO FILL IN �u1LDING
❑ • ADDRESS
Certified copy is hereby furnished: L suILDIriG
kk OCALITY
D ADDRESS 5853• Temple Cit Bl-vd.- -
Certified copy is filed with the county building.inspection 1k EAREST
department. LOCALITY � 'lc Rle Cit�zf CA OSS ST.
Date Applicant NEAREST IDISTRICT N OU TYPE .FROG SSEO BY
CROSS.ST. Las Tunas 'Drive �' CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I `+� A'-2
DESCRIPTION LOT NO. BLO CIC t ! h�"7 STATE MAJOR SECOND LOCAL
COMPENSATION INSURANCE MAP r+IGMwwr }
NO. OF BLDG'S. :N,O. �10 7 (CIRCLE)
(This section, need not be. completed if the work involved TRACT NO.W ON LOT 113E ZONE SPECIAL CONDITIONS ('
by the permit is for one•hundred"dollars ($100) or less.) U
• USE /�
SIZE OF LOT � EXIST ING BLDG.
I.certify that in the performance of the work for which this
1y
permitpermit is issued, I shall not employ any person in any manner 'i' OWNER O 0
so as to become subject to the Workers'Compensation Laws. I I OCCUPANCY GROUP W
S _MAIL 5853 .Temple City .Blvd.
ADDRESS0.
Date Applicant �, rEL W
NOTICE TO APPLICANT: If, after making this Certificate'of ): =C.ITY Temple -C'ity ND.285-99'02 1•• OCCUPANT LOAD —
Ezeinption, you should .become subject to the Workers' 1
Compensation provisions of the Labor Code; you must"forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be 'I; TRAILER USE GEOLOGY INSPECTION No Spec. KnOWI. Q
deemed"revoked. •' � _ � r P ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION. Panic D@VICE$
I hereby affirm that I am licensed under provisions of Chapter j SAFETY PERMIT,Q (LIST ITEMS BELOW) I' NO. OF EXITS
9 (commencing with Section'7000)of Division 3 of the Busi-,f. i
•n.ess and Professions Code, and my license is in full force and I ARKING.
effect. REq'D PROVIDED
PACES
License Number Lic.Class
LIMITED TIME-USE
Contractor Date - owr•e TO: DATE ,
'I am exempt .from OM:
the licensing requirements.as I am a.
er
licensed architect or a registered professional engineer I SIZE OF NO. OE INSPECTOR'S
44
acting ill my professional capacity (Section 7051, Bus-I , EXISTING BLDG. STORIES },1 SIGNATURE
mess and Professions Code). r PRESENT USE.OF BUILDING empty l�INAL APPROVAL
Lic.or Reg.No. Date
NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION b
ON LOT AND USE n� -
I hereby affirm that- I am exempt from the Contractor's j;. {+41
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):' No. PARKING
SPACES PROVIDED 1 �1 8,8 A
.I, as owner of the property, will do the work and the • �'
structureis not. intended or offered for sale (Section N
FFFN # d,o 0 0 8 8
7044,Business and Professions Code).
,C ,
-PROPOSED USE OF BUILDING•Of.f1Ce for design is
CONSTRUCTION LENDING AGENCY 1o;a I o o I e o 'O
'T
I hereby affirm that there is a construction lending agency Is 0 9 1 b—8 1
for the performance oT the work for which this permit is
issued,(Sec.3097;Civ.C,).
Lender's Name PROPOSED MAX. OCC. '
Lender's AddressS.
PERMIT FEE iv
'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 1
Mgt.
e laws relating to building construction, , TOTAL FEE
e representatives of this.County to enter I Soo
tinned prop ty .for inspectipn urp.oses. $ E REVERSE FOR.EXPLA ATORY LANGUAGE
y/�tT/ �,I
S nature o P ittee Date
lo
1