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HomeMy Public PortalAbout5949 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION I 76M444 CE 875(11-84) M ISCELLANEOUS APPLICATION {� I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION' LI insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. f Policy No. Company FOR APPLICANT TO FILL IN BUILDING I ADDRESS 4L AJUD Certified copy is hereby furnished. BUIL su LOCALITY i Certified copy is filed with the county building inspection 1 ,6004LOCALITYNEAREST department. &!X . eA 171700 CR OSS ST. Date Applicant NEAREST DI$W{I G TYPE PRO BY CROSS ST. y✓1 P1 I CONST. L CERTIFICATE OF EXEMPTION FROM WORKERS' I LEGA / COMPENSATION INSURANCE I DESCRIPTION LOT No. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJORS OND OCAL NO. OF BLDGS. (This section need not be completed if the work involved I 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. I certify that in the performance of the work for which this i CD permit is issued,I shall not employ any person in any manner OWNER Up&I 1 � S 2AJE5Q Com] � 1= so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o ADORES ~ Date Applicant NOTICE TO APPLICANT: If,after making this Certificate of CITNe 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 oI this permit shall be I TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTI 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 andI� effect. tzr_ PARKING REq'D � I PROVID8D I SPACES J ��JJ License Number Lic. Class DpIruq Dom(4 rs. LIMITED TIME USE Contractor. Date DATE DATE I am exempt from the licensing requirements as I am a , licensed architect or a registered professional engineer. size of NC.OP FROM: To: NSPE To R'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING • "� —� \ Lic.or Reg.No. Date 'r . C� . Ma" O E 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- I 0000_0001 6/ 6/90 ness and Professions Code): NO. PARKING I ElI, as owner of the property, will 'do the work and the SPACES PROVIDED 1137 f PM 3e 12 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY I PROPOSED use OF BUILDING I hereby affirm that there is a construction lending agencyI — - for the performance of the work for which this permit is 5 issued(Sec.3097,Civ.Q. Lender's Name i PROPOSED MAX. OCC. Lender's Address I 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, and.hereby authorize representatives of this County to enter 'rO"rAL FEE upon t77he above-mentioned property for insp t' n purpos s. o SEE REVERSE FOR EXPLANATORY LANGUAGE 4VQreof Permittee Date WORKE1tS'COMPENSATION DECLARATION CE 8754(„-s4) M I SC E L LA N E O U S APPLICATION I herelao 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,ori a certified copy thereof(Sec.3800,Lab.Q. � Policy No. Company FOR APPLICANT TO FILL IN BUILDING pODRE33 Certified co is hereby furnished. BUILDING PY Y �1' + ��/ LOCALITY DDRESS Y 0 Certified copy is filed with the county building inspection LOC'ALITY,e.-� p NEAR STr. department. l Date Applicant NEAREST I GISTRFNO tU TYPE PROLE D BY I CROSS ST. _ J!! C.O ET. CERTIFI4QATE OF EXEMPTION FROM WORKERS' I LEGAL COMPENSATION INSURANCE I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY N.O. (CIRCLE) STATB MAJOR SECOND OCAL • NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONEF IAL CONDITIONS by the permit is for one hundred dollars ($100) or less. USE OF I certify that in the performance of the work for which this % ZZ OF LOT EXISTING BLDG. d permit is issued,I shall not employ any person in any manner NER I J so as to become subject to the Workers' Compensation Laws. MAIL L �•�• - OCCUPGROUP o DRESS 1"""• Date Applicant I <;; u�l NOTICE TO APPLICANT: If,after making flus Certificate of• CITY No. _ d OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICA ION 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 ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPBCTION 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- NO. OF EXITS ness and Professions Code,'and my license is in full force and effect. PARKING R6Q•D PROVID 6D SPACES License Number Lie. Class • LIMITED TIME USE Contractor Date DATE DATE ❑ 1 am exempt from the licensing requirements as I am a PRDM. TD. licensed architect or a registered professional engineer. SIZE OFD J� f�� NO. OF INNCOR•S acting in my professional capacity (Section 7051, Bus- E STING BLDG. a STORIES / ATTURE iness and Professions Code). P ' J.J �QujL��/V FINAL APPROVAL PRESENT USE OBUILDING lav /! .� Lie.or Reg.No. Date g _ .HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS ON LOT AND USE A 9.1 9 I hereby affirm that I am exempt from the Contractor's #,a o D o g License Law for the following reason (Section 7031.5, Bpsi- ness and Professions Code): No. PARKING SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section j 7044,Business and Professions Code). r CONSTRUCTION LENDING AGENCY I PROPOSED USE OF BUILDING V• I 5 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 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 law rely 'ng to building construction, hereby authorize r res tives of this County to enter TOTAL.FEE f on the above-menti ed erty iAspectio urposbs. ; EE REVERSE FOR EXPLANATORY LANGUAGE S• nature ermit e Date