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Home My Public Portal About5948 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a cgIrtificate of Workers'Compensation Insurance,or fl a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL.IN BUILDING qg G � ADDRESS b Certified copy is hereby furnished. wu ILD Wenlole LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. ceoss ST. b b Date Applicant NEARESTr[)CROSS ST. Mrj DI§TB. 61 ICT NO (T GROUP TYPE 1PROQESyD_8Y W V �/.J CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP So HIGHW NO. OF BLDGS. NO. (CIRC AY STATE MAJOR SECOND LOCAL LQ) (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. 6- 01 certify that in the performance of the work for which this I o permit is issued, I shall not employ any person in any manner OWNER LOUT s A;�_ Ek y so as to become subject to the Workers'Compensation Laws. MAIL 1 AveCUPANCY GROUP oADDRESS L-eVT' an I y V Date Applicant L„ NOTICE TO APPLICANT: If,after making this Certificate of CITY l�. qu�l TEEL, 6`7 OCCUPANT LOAD N 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 ❑ E] No Spec. Knowl. deemed Ievoked. TRAILER USE GEOLOGY INSPECTION LICENSED CONTRACTORS DECLARATION OCCUPANCY 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 and effect. PARKING REQ D PROVIDED SPACES License Number Lic. Class I LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a y licensed architect or a registered professional engineer SIZE OF /`A NO. OF FROM; To: InSIG TORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. AD STORIES SIG ATURE inessand Professions Code). FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING v'U HOME OWNER-BUILDER DECLARATION NO. OF CXbSTING BUILDINGS Nn FEE 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. PARKING 0 I, as owner of the property, will do the work and the SPACES PROVIDED 4875 1 Prii 3530 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 agency an ZYt� for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. � O Lender's Name PROPOSED MAX. OCC. 110) Lender's Address �� C7 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 and State laws relating to building construction, llllll and hereby authorize representatives of this County to enter TOTAL FEE I o the above-mentioned1popertI i,y for inspectio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Q 1 Signature of Per ittee (J D to 1 hereby affirm that ) 1mve a certdltate of onaeut to ,.C!f it:�;era. :cert,til::lteof%)rkers'C ompenstion ;nsumnce. fr COUNTY OF LOS .--\\G EL':S BUIL MUNIG ANL' SAFETY DIVISJON i ' -I c,rdfi,Jd Copy thereor tSec.3800,Lab.::.). ,r Polirl-Nc• ---.--C`ompan}'— --.— -- FOR APPUCAN T, •''C CIL'- 1Nau1LD:;,G n`.7 i p� - ADDRESS C Certified copy is hereby furnished. ,I XX 111 ADDRESS S/ LOCALITY DCertified copy is filed with the;ounty building inspection LOCALITY �NE AREaT department. X>r. ,,CROSS ST. Date-__ Applicant F ^ — _ NEARES y� ( II DISTRICTO i GR P iTT ONS CESSED BY �:-OSS )j �4L.t I \a 7 1 CONS CERTIFICATE OF EXEMPTION_ROl11FORKERS' IFGAL li CONIPENSATIONINSLRA`.0 I ? GESCRIPTrON (LOT N . iBLOCK 'AAP HIGHWAY STATE MA,OR SECOND LOCAL T--OF B NO. (CIRCLE) II'_ Nr fiP aLDGS. (This section need not be completed it the wor:c inr oivetl rRl C- IND Vt 7N LCT j1:SE 20 NEI SP E.=IAL CONDITIONS by the permit is for one hundred dollars (5100) or less:) --'—'"— "T aF - SIZE OF LO'f i EXiS-7NG BLDG. I I certify that in the performance of rise work for which th s permit is issued. I shall not employ any ❑e:son in any manneX- X O%VNER Of building e r so as to become subject to the'Yorkers' Compensation Laws. NAIL /_ G? �� i' OCCUPANCY GROUP ADDRESS �l Date— Applicanr _ TE r / G T'L' �/� { OCCUPANT LOAD NOTICE TO %PPLI�'ANT: !f, after iral utg this Cer�ificate of I clrY lQ ND. - Exciaption, you should become CUbje:t rc the Worker,: -- Compznsittion provisions of the Lailcr Code,you must tori- i— aPP �.A i ION =CP 3 cX 1-H.ARDWARE: .++ --1 .vi It comply with such provisions or this permit shall � I_,A, — — ! � L=R USE : G EOLOG`� !r.SPE:TION i_! I`Q Spec. i\r!Otllfi. deelneri revoked. s -- 1 O I:CLIPAN CY Panic Devices :N5PEC":CN^_ LICENSE D+'.ON j'R ACTORS I)ECLARATIO N ---- — L_ I hemby artirm that 1 am :lz:nsed:.title-D:oYIsion,;o t•Ilapror ! SAFETY -FrRrA:T '^ --:S- IT=:AS BELOW) I �� 9 ico:nmen•:ing with Set'(,i -0011. -if Division 3 of:he Bu%'- t — 1 No OF EXITS ness :lnd Prof9ssions Code. an(I :nj license is sr foil force ar" I effect. �X3�1E OL business___-- ' RK4h�G RECD PROVIDED I II License Number —_ [_i:. :l.tss---- -._---- � t1�Y1�F! 121A(,� LIMITED ;Inns use Contractor _ Dl.e-- --� -----.-- Off•-- CATE FI am exempt from the li.crbir._ requirements as 1 am�: -- il'R4 TO: — licensed architect Or a :esnstered professional engincC. INSPECTOR'S SIT:. 7r• VO. OR acting in my professiom:l caDacay (Section 7051. BuJr EX]iTI N:: a�7 G. IVO V STOR,=5 I -- - SIG ATURE iness and Proiessioilc Code I. —� I I=iNAL APPROVAL MM JJJ PR ES.:^IT USE OF BUILDING ---- Lice or Re_.tip._ _ Date_ � s-- — __ _ HOME OWNER-BUILDER DECLARATION FNo. :F EXISTING- 3UILDIN.s ---- it 0 lON LOY AND :JSd 0 I hereby affirm that 1 ant exempt front the Contractor License Law for the following- reason (Section 7031.5. Bus.- ness and Professions Code): NO- SPACES O. P,?4riIYG SPACE'• PROVIDED 71 1, as owner of the property. will do the work and tae structure is not intended or offered for sale tSection — 7044.Business and Professions Codes. I ------ --- CONSTRI:CTIONr LENDING AGENCY I PROPOSED USE OF BUILDING ' I hereby affirm that iliere is a tion:,trlc*ion iendi ne a--enc for the performance of the work for tt hich this permit In --- issued(Sec. 3097.Civ.C.I. Lender's Name _ s I PROPOSED IN.i.=" Oij lam=. Lender's Address -- wr`,r•?I ; PERMIT FEE 25 I 00 I certify that I have react this application and state that til.. ! 1 ' above information is correct.i agree to comply with all County ISSUANCE FEE y ordinances and State laws reL-iting to building construction. ,=1 ' and hereby authorize representatives of this County to enter TOTAL FEE 25 ,001 upon the ab e- :entioued p arty -nr islspeetion purposes. - l' � �fii. SEE REVERSE FOR E\PL.�\:TORY LA\Gi•.aGFt t) XX XX 3' O o ?x. Signature of Permittee ate 5>�