HomeMy Public PortalAbout5945 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875
(11-84) M I SC E L LA N EO U S APPLICATION
I hereby affirm that I Have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
BUILDING
Policy No.-_, `
Company FOR APPLICANT TO FILL IN ADDRESS 4 `
Certified copy is hereby furnished. AuoREss , LOCALITY L_ 1
❑ Certified copy is filed with the county building inspection LOCALITY —re--^7.I 1• I��7p/� NEAREST
department. ceoss sT. t.tGL
Date Applicant EAREST ^ /A' DISTRICT NO. GR,pUP TYPPROCB¢SED BY
CROSS ST. {(� Jfj�p CONT +/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL.
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. /// / cLGY STATE MAJOR SEC�LOCAL
NO. OF SLOGS. ( iRC
'"'•
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SP IAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF l /
SIZE OF LOT EXISTING BLDG. [/
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER .t'0,41 //).'ZZ 16�Alp % //STEP .
so as to become subject to the Workers' Compensation Laws. AAAIL OCCUPANCY GROUP IL J
ADDRESS Q�+L�� �•�ll I/C` ��� d VI/`� O
Date Applicant ��++
NOTICE TO APPLICANT: If, after making this Certificate of CITY Lt9, Re 11qZy 1114L I'JJ3"6S3 9,,07 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. El
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PER MI ❑ (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 and
effect. PARKING REq'D D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
F] I am exempt from the licensing requirements as I am a
FROM: O:
licensed architect or a registered professional engineer SIZE OF NO.OF I SSGNATUR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
/� A
iness and Professions Code). pry CL 4NI N FINAL APPROVAL _Q '
PRESENT USE OF BUILDING _
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS G 8 2 5 3 A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ��� # o o o o 8 8
License Law for the following reason (Section 7031.5, Busi- ` ��
ness and Professions Code): NO. PARKING \� o G G D D,o o 0
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for We (Section l
7044,Business and Professions Code). ( 1. 02 -87
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
1 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 d9
1 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 and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL, FEE o�j jam,Od
on the above-mentioned pro rty fo ction purposes.
� �E REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitte /��"Date