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Home My Public Portal About5947 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE B75(11.84) MISCELLANEOUS APPLICATION C CE 876 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES -+961LBING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING � W7 y ADDRESS 7 Ci G Certified copy is hereby furnished. XX DU ADDRESZJ 9y/ ACPLITY Certified copy is filed with the county building inspection LOCALITY CROSS s .1011— department. XX LOCALITY Date Applicant NEAREST DISTRICT NO. I GROUP TYPE P ESSED BY CROSS ST. �D CONST? CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL G COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO.OF BLDGS. No. (CIRCLE) (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.) USE OF, SIZE OF LOT EXISTING BLDG. �� O 1 certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manned OWNER of buildin so as to become subject to the Workers' Compensation Laws. MAIL ////��JJ / OCCUPANCY GROUP ADDRESS gPr&f Date Applicant NOTICE TO APPLICANT: If,after making this Certificate of CITY L� % RrNo� OCCUPANT LOAD 7 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. KnowL deemed revoked. LICENSED CONTRACTORS DECLARATION occuPANcr INSPECTION ❑ Panic Devices I hereby affirm that I 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 anix effect. Name of bus'ness PARKING REWS) 1 J PROVIDED I —J PACESLL-- License Number Lic. Class LIMITED TIME USE Contractor Date• DATE DATE i F1 I am exempt from the licensing requirements as I am a � FROM. TD. INS licensed architect or a registered professional engineer SIZE OF No.OF GNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). FINAL APPROVAL K-3-94) � -• y_- Lic.or Reg.No. Date PRESENT USE OF BUILDING HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �'/�` qI {±[ryq =, • ;r.u� ON LOT AND USE 9 / V �IL 47i„FJ 0/ I hereby affirm that I am exempt from the Contractor's ( License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING V/ 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 I hereby affirm that there is a construction lending agencyfor 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 25.00 r°r above information is correct.1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, 25 0� and hereby authorize representatives of this County to enter TOTAL FEE '1 upon the above- entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX • Signaturc of Pcnnittce Date 1 WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N I hereby affirm that I have a certificate of consent tself CE 875 (11-84)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. Policy No. Company FOR APPLICANT TO FILL IN BUILDING pODRE55 Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS (i Certified copy is filed with the county building inspection LOCALITY NEAREST department. edy CROSS ST. Date Applicant NEAREST DISTRICT NO. I GROUP CONST. PROCESSED BY CROSS ST. Q of r CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) us9 OF I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. O permit is issued,I shall not employ any person in any manner OWNER b, y so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o Date Applicant q ADDRESS ! U NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. ! OCCUPANT LOAD z 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. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter I 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 and effect. PARKING REQ'D PROVIDED SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE FROM: To: ElI am exempt from the licensing requirements as I am a I licensed architect or a registered professional engineer SIZE OF NO.OF I SSGECTURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG.G. STORIES iness and Professions Code). FINAL APPROVAL Lie.or Reg.No. (Date PRESENT USE OF BUILDING ! / 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- ness and Professions Code): NO. PARKINGEJ :-_I- • _? I, as owner of the property, wSPACES PROVIDED ill do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE OF BUILDING .' 41. CONSTRUCTION LENDING AGENCY ` _i.�:i_—I�i_;�i �: _. I hereby affirm that there is a construction lending agency _Its y y + o97, for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. „' Lender's Name L_U 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, -2 O and hereby authorize representatives of this County to enter TOTAL FEE 1:25 1 on tl abo e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ' ature of Permittee Date WORKERS'COMPENSATION DECLARATION a CE 875 (11-84) MISCELLANEOUS APPLICATION CE 87 1 here) 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.). BUILDING " Polic§No. Company FOR APPLICANT TO FILL IN ADDRULDING ESS Certified copy is hereby furnished. uILDING �"'�� /�� LOCALITY ADDRESS Certified copy is filed with the county building inspection OCALITY �)l� �x-740 NEAREST department. f / cRoss sT. ' Date Applicant CROSS ST. �� DISTRICTIyO/ G�qO/ P T ST. PR`ESSED BY PP Qeoz&l;" II�![[JJ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF HLD GS. (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.) USE OF 39R OF LOT EXISTING BLDG. a 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 WNER so as to become subject to the Workers' Compensation Laws. MAIL ��} OCCUPANCY GROUP o ' � - C3 �J� A DRESS Date Applicant �/ _ ^e � NOTICE TO APPLICANT: If,after making this Certificate of CITY .G� L (j��LO�ivo� OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code,and my license is in full force and T,eFAI�/ ?��v effect. PARKING SPACES RHQ'D PROVIDED License Number Lic. Class • LIMITED TIME USE Contractor Date v `� �i ' • DATE DATE FROM: TO: Elam exempt from the licensing requirements as I am a OW_ ��ie licensed architect or a registered professional engineer SIZE OF NO. OF IN SSPE CTOR s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES C3't; URE iness and Professions Code). FINAL APPROVAL c PRESENT USE OF BUILDING Lic.or Reg.No. Date , � VXI?4ti/ GO-P8 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE f� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING J El I, as owner of the property, will do the work and the SPACES PROVIDED lJ structure is not intended or offered for sale (Section 7044,Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency /� �� C&"5 ` 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 cps, OQ PERMIT FEE I certify that I Have read this application and state that the above information is orrect.I agree to comply with all County ISSUANCE FEE ord' and S laws relating to building construction, and liereb aet p e representatives of this County to enter TOTAL FEE , u on � o.e- anti d property for>insp purpos SEE REVERSE FOR EXPLANATORY LANGUAGE �j1 Sipature of Permittee Date