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Home My Public Portal About5909 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCE LLANEOU S APPLICATION I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING 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 / �" ❑ ADDRESS & e Certified copy is hereby AIMJILDING / LOCALITY q ❑ ADDRESS V Certified copy is filed with the county building inspection ' NEAREST department. -LOCALITY AI CROSS ST. Date Applicant EAREST DISTRICT NO. GROUP TYPE PRO SSED BY CROSS ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY } NO. OF BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL 0. (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.) i USE OF U SIZE OF LOT EXISTING BLDG. �f Q± I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner I NER G, so as to become subject to the Workers'Compensation Laws. I M �L OCCUPANCY GROUP LU 'AODDRESS Igg in Date Applicant �� U) TEL. NOTICE TO APPLICANT: If, after making this Certificate of r No. OCCUPANT LOAD Exemption, you should become subject to the Workers' 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 U.SE❑ GEOLOGY INSPECTION No Spec. Knowl. ❑ deemed revoked. PanIC Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION thereby 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. i REO'D O PROVIDED , SPACES LL��JJ License Number Lic.Class LIMITED TIME USE Contractor Date I DATE DATE ❑ FROM: TO: I art 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- I EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). IRESENT USE OF BUILDING I FINAL APPROVAL Lic.or Reg.No. Date ( ea3 HOME OWNER-BUILDER DECLARATION I NO.OF EXISTING BUILDINGS ON LOT ANO USE =� I hereby affirm that I am exempt from the Contractor's 9'4 9, 1 A License Law for the following reason (Section 7031.5, Busi- I }` o 0 0 0 8 8 ness and Professions Code): NO.PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and the 0 0 0 0 0 0 0,� structure is not intended or offered for .sale (Section 7044, Business and Professions Code). IC 201 —83 ptels-PoSED USE OF BUILDING 9 B0 CONSTRUCTION LENDING AGENCY I C I hereby affirm that there is a construction lending agency i for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). I 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 laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter upohe above-ni Sed prXperyor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE / u v Signature of Permittee Date I L4 R'OR1:EItS'(:0111PENSATION DECLARATION 'CE 875(11.84) M ISCELLAIR OU_S APPLICATION I'hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES � WILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or i as certified copy thereof(Sec.3800,Lab.Q. I Policy No. _—Company FOR APPLICANT TO FILL IN BUILDING�O ` ADDRESS Certified copy is hereby furnished. BUILDING OCA LIT, XX ADDRESS J D� Certified copy is filed with the county building inspection LOCALITY •NEAREST department. 3CX CROSS ST. Date _Applicant—_ NEAREST DIST DCT Stp. CO g CESSED BY CRerl OSS ST. ITYaJ/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL O. OF SLOGS. (TIAs RCCtIPn need not be completed if die work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) uSE of ,/A E SIZE OF LOT XISTING BLDG. C_(� I certify that in the performance of the work for which this D permit is issued,I shall not employ any person in any manne3EXl OWNER of bu•ldin ry c %I as to 11CC0111C Subject to the Workers' CompensationMAIL Laws. OCCUPANCY GROUP O' o C ADDRESSr- Date----Applicant — , �/• u Nona: TO APPLICANT: If,after making this Certificate of : CITY NOL pp/3 l0J1/-1A34$' OCCUPANT LOAD 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. 1 OCCUPANCY INSPECTION ❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirrn that 1 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 anJX effect. I Name of business PARKING RE E� PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor- Date __ DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered profbssional engineer ; SIZE OF NO.OF 1 SSPNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date / -1 HOME;OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE )\ •A I hereby affirm that I am exempt from the Contractor's License Law for file following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 1 (tereby affirm that there is a construction lending agency for the performance of the work for which this permit is !.I issued(Sec.3097,Civ.C.). Lender's Name I PROPOSED MAX.-OCC. Lender's Address—_--__ — Ca 1 !aar bove drat I have read this application and state that the PERMIT FEE 1— : i above information is correct.I agree to Comply With all County ISSUANCE FEE -p ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 Mr ;... upon the above-nteatIioned.property f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX Ci!n•iinrr �f I'rlmillrl- \IIIc - `