HomeMy Public PortalAbout5925 TEMPLE CITY BLVD_Miscellaneous__ I - \tOR1:lRS'('0>IPENSATIONDEC'L.kR:>'r10X 875 1,•841
CE MISCELLANEOUS APPLICATION rI"
�„ � •-.,,' CE 875
I hereby affirm dant 1 have a certificate of consent to self COUNTY OF LOS .-ANGELES BUILDING AND SAFETY DIVISION '
insure.'IJr a certificate Ut«'orkers'Compensation Insurance.or
01 �l - a certified copy thereof'ISee.38110.Lab.C.1. =-tr
•, Policy'*o. —C oninan) FOR APPLICANT TO PILL IN BUILDING >
ADORES �d
Certified copy is hereby furnished. BUILDING LOCALITY
R ADDRESS f �L
' ❑ Certified copy is filed with the count, buildine inspection LOCALITY IF NEAREST
department. Temple City CROSS ST.
Date Aorilicant NEAREST DISTRI NO/, GR UP TYP ESSED BY
' CR055 ST.
O y 6i{ CON
I
CERTIFICATE OF EXEMPTION FROM'VORKE•RS' LEGAL O �• /
COMPENSATION INSUR\NCC- DESCRIPTION LOT NO. 'BLOCK !MAP wIGHWAT
�I •l G. )CIRCLET STATE MAJOR SECOND LOCAL
NO. JF BLDGS.
(This section need not he comolered If the nark involved 1-RAC- NOW ON LOT USE ?ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars +51001 or less.) ?
1 �SIZE OF LOT I USE OF !
I certify that in :he Performance �i he :s.\rk fur which -his kox Up=x
EXISTING BLDG• �_ —_
permit is issued. I ,hall not employ ans. '12CMn :n inv mannerDwNER [ o
so as 'o become euhiect :o the 1V('3rkerc' I';nl^ensation !.a\1 C. MAIL y//h p OCCUPaNC" 3ROL'P —_
ADDRESS /✓ C/C J
I Date Applicant _ _
NOTICE Tr? APPLICANT- If. :ri:e--nakinc :!s+ ^tic:ttc �: $I CIT" qa - &L F-2 �✓fO QCCUPcN-LOAD
Eeemotio-1. \'Uu should become :uiaec- :•o -he I%- ger
[:o m!rns:.:uln provisions •li:he Labor .iaL. %•rnl :nus[ tnr:h-
! with cnmaiy ivith .tich ^rovi%:on< iii, ernllt ;hall he - — 1� i
deemed:c\'�P2C[. ,- 'R AILEA USE � vEO LJ GY 'NFP=CT:CV — I`l0 Sties. I(•\C,y1
- LICENSE DiOXl'RACTORS DL•CLAR.a!IOZ 7CC:JP ANCY INSPECTION$$
Manic De—res ❑
_ I hereby affirm :hat I am licensed under. r.rcvislons o!(Ilal le! SAFET• PERMIT LIST ITEMS BELOW)
' 9 Icommencins with Section -0001 of Division -1 )1 the dusi- — NO. OF EXITS
ness and P—iessulns Code.and my licence is in .full 1rrce and /J�
et[el•:. t/Yy�dC/� PARKING
w I SPACES REO'D I PRCVID ED
Liccnse Gunther_ Lic. C!a.,
LIMITED TIME USE
I'1 C'Ontraclnr-____ !kilt_ DATE DA-F
EJ LL
V:Y.
I .tin exemptt:om :he :icensin� recut;e:nen[s as I am .1 .D.
m I licensed archnec- or a reaistered ^'nlessional ent:ineer slzE OF IIISPECTOR•S
z actin_ :n 'n:• prl•te'•sll,n:ll- :^I.::i•• 1::•:,,'+ -I\:1• !;ll`• I EXISTING BLDG. I;-7P�c5 SIGNATURE
—._.
itle'slinl"7oeiiicn\t ode+. FINAL APDRO\l.4L
�j
'RESENT USE OF BUILDING P
Lic.lir ReL. \o.--- --. D.;-.
- I
HOME ORNI R-I;l ILDER DI:(.•L.mz.%ri0N NO. OF EXISTING BUILDINGS 60 U
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License La,s for the following reason 'Section -11:1.:. liusi- -e®r
tress and P:oiessions Code): No. PARKING
I• as .-lwner of the property. will do :Ile work and the SPACES PROVIDED
structure !s not intended or offered for ale ISectlon
704.1.Iiusincss and Professions Cndel.
CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lendins ;L-cnc%
for the performance Of the work for which this permit is L C.1
issued ISec. 3007•Civ.C.).
Lender's Name yr QUI
PROPOSED MAX. OCC. !�
Lender's Address
25.00
I certify that I 112VC read this application and state that the PERMIT FEE F-+• r m If,I
above information is correct. I aarce to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction
• 25.00 •-�•
and hereby authorize represen ives of this County to seenter TOTAL FEE -T.+ 1
! I upon tyle hove-mented pr ert} fUr ir>xpection pt[rpos. -t .-,-
SEL REVERSE FOR EXPLANATORY LAVGC'AGE 4;_ ;
Signature rlf mittee Date -• •c'•