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HomeMy Public PortalAbout5935 TEMPLE CITY BLVD_Miscellaneous__ � ,vIPENSATION llECLARATION CE 876(11-84) MISCELLANEOUS APPLICATION I hereby um that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION �f a certified copy thereof(Sec.3800,Lab.C.). BUILDING Policy No. f Company FOR APPLICANT TO FILL IN �J ADDRESS 33 �. ✓� n F1Certified copy is hereby furnished. Bu1LDING a 3 C` /� LOCALITY ADDRESS lJ I ly 0 Certified copy is filed with the county building inspection LOCALITY NEAREST ' department. CROSS ST. L . . Date Applicant NEAREST ( ISTRICT NO. GFF��Oy TYPE PROCESSED BY CROSS ST. S /L( ���ii G CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL U COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SEGO LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITI JlYS"`— by the permit is for one hundred dollars ($100) or less.) USE OF (!I_- 1 v iz I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. 01 o permit is issued, I shall not employ any person in any manner VOWNER ( - so as to become subject to the Workers' Compensation Laws. MAIL ^/ P CC OCCUPANL4 GROUP L o Date Applicant ADDRESS a�93 iii v NOTICE TO APPLICANT: If, after making this Certificate of CITY %� I , NO. — I OCCUPANT LOAD Exemption, you should become subject to the Workers' IA PLI TION FOR EXIT HARDWARE: —' Compensation provisions of the Labor Code,you must forth- 1 with comply with such provisions oI this permit shall be TRAI ER USE GEOLOGY INS ECTION deemed revoked. ❑ ❑ ' No Spec. Knowl. LICENSED CONTR CTORS DECLARATION OCCUPANCY SPECTION Panic Devices I hereby affirm that I am lice sed under provisions of Chapter SAF TY PERMIT ❑ (LIST ITE S BELOW) 9 (commencing with Section 00) of Division 3 of the Bu si- 1 NO. OF EXITS ness and Professions Code,and y license is in full force and J effect. PARK NG REO'D D PROVIDED SPAC S License Number ic. Class `' LIMITED TIME SE Contractor D to ) DATE DATE PROM: i TO: I am exempt from the licen ' requirements as I am a I licensed architect or a register d professional engineer s,zEroF NO. OF s INSPECTOR'S acting in my professional capac y (Section 7051, Bus- EXI `PING BLDG. STORIES SIGNATURE iness and Professions Code). Q F'i NA L APPROVAL. PRI)SENT USE OF BUILD G Lic.or Reg.No. ate HOME OWNER-BUILDER DECL RATION OF EXISTING BUILDINGS 8 3 1 A �N•LOT AND USE �► # 0 0 0 0 8 8 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sect n 7031.5, Busi- 0 0 o D o 0 0 ness and Professions Code): NO. PARKING El I, as owner of the property, will do the ork and t SPACES PROVIDED 11. 17-87 1 7 8 7 structure is not intended or offered for S on 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of B ILDING S I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ordinances ayq State laws relati to building construction, and here thoriZe represent iv s of is Count to enter TOTAL FEE upo ]t a e-mentioned op rty for i spection p rposes. � 1 � S E REVERSE FOR EXPLANATORY LANGUAGE 'Signature of Permittee ate 0�! WORKERS'COMPENSATION DECLARATION 76M444 �/� ��++ pp pp pp ((�� � gg APPLICATION/� w' a r CE 875(2-80) I� IS`>asEllal�(�®I�II EUS APPLICATION I lure,o affirm that I have a 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 APPLICANTTO FILL IN BUIADO KESSLDING _3T E] f Certified copy is hereby furnished. BUILDING -7-AW �+ ADDRESS 5-93�,���G�ci, LyD. LOCALITY ❑ Certified copy is filed with the county building inspection NEAREST department. V LOCALITY CROSS ST. Date Applicant v NEAR ESTif /,,,/ DISTR�`?� GRQjIP ROC TYPE / PE BY CROSS ST. GdS _(//v AS (xJ CONST. O,Y•// CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRiPTI ON LOT NO. BLOCK MAP HIGHWAY } No. F BLDGS. NO. (CIRCLE) STATE MAJOR SECON OCAL d (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS Q by the permit is for one hundred dollars (S100) or less.) U USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this �/g'^ 0 permit is issued, I shall not employ any person in any manner OWNER Q� o A-SI -PEW71-//Q e so as to become subject to the Workers'Compensation Lawk<, �yy �% s' ///A� _ e7�1 OCCUPANCY GROUP U �� MAIL O V V✓/ 111de1+ �� v d ADDRESS Date Applicant U) TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITY 61 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 TRAILER USE GEOLOGY INSPECTION NOSpec. KnOWi. ❑ deemed revoked. p ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (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 ppRKlNc. effect. SPACES REQ'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES JPIGNATURE iness and Professions Code). \� PRESENT USE OF BUILDING / FINAL APPROVAL '��� Lic.or Reg.No. Date l/ ( i HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS # 0 0 0 0 3 Q ON LOT AND USE I hereby affirm that I am exempt from the Contractor's o 0 0 o 0 0 0 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No.PARKING SPACES PROVIDED 0 �,0 9-8 7 ❑ I, 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). V PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 1:r (gyp I hereby affirm that there is a construction lending agency f for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE V I certify that I have read this application and state that the r� above information is correct.I agree to comply with all County ISSUANCE FEE �\ ordinances and State laws relating to building construction, TOTAL FEE LX v �\ 1 and hereby authorize representatives of this County to enter Pon the-,�above-uien ' per inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE M—A d171/ Si ature of'Permittee Date