HomeMy Public PortalAbout5916 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION I 76M444 MISCELLANEOUS APPLICATION
I hereby affirm that I have certificate of consent to self CE 875(2-80)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
PolicyNo. Com an BUILDING
Company- FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is hereby furnished. BUILDING /�'G ) / J LOCALITY r•
ADDRESS / - Cif � .� I! L+v ,I �. J-: �7• i ..+L•�"
❑ Certified copy IS filed with the county building inspection NEARESTdepartment. LOCALITY fC#1',4ff C/7-• 1L. 7/�G0 -
CROSS ST.
Date Applicant NEAREST f '+- A DISTRICT NO. ' GROUP TYPE P VE ESSED/BY
CROSS ST. r�v+ I`.! .I, CONST.(�•�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL =
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK yHIGHWAY
• NOP ' • r + (CIRCLE) STATE MAJOR SECOND LOCAL O
(This section need not be completed if the work involved NO. OF SL T USE ZONE SPECIAL CONDITIONS W
P TRACT NOW ON LOT
by the permit is for one hundred dollars ($100) or less.) 1 usE OF J
ZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this LL
permit is issued, I shall not employ any person in any manner • OWNER L�ukll� ��/� >_
so as to become subject to the Workers'Compensation Laws.. MAIL I• _ OCCUPANCY GROUP pc
Date Applicant ADDRESS ) /ol� �(=11�1�, 6 ,&V,{ • Qf?:
TEL. U O
NOTICE TO APPLICANT: If, after making this Certificate of CITY7Z 11Ay'M C/1-ry NO. "I u7 ?GfJ7 OCCUPANT LOAD a
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: W
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ ~
deemed revoked. ❑ NOS @C. K110Wi.Panic Devices ❑
LICENSED 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 I PARKING.
effect.
SPACES REQ'D PROVIDED
License Number Lic.Class LIMITED TIME USE
Contractor Date GATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
IneSS and Professions Code). PRESENT USE OF BUILDING UJ 71 •1`LC 1f) � FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
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- I .j Pness and Professions Code):
NO.PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the " a o o D t
structure is not intended or offered for sale (Section
7044, Business and Professions Code). u a D 0'0 O q l '
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY r y�17 /tI�F S7/45 f� »(jil.a
I hereby affirm that there is a construction lending agency AS
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name PROPOSED MAX.Dec.
Lender's Address PERMIT FEE
I certify that I have read this application and state that the ISSUANCE FEE
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction, TOTAL FEE
and he eby authorize represented es of this County to enter
upon. h abov -men#ioned pro�rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
JJJJJJ 3 -
Signature of Permittee Date
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