The URL can be used to link to this page

Home My Public Portal About5951 TEMPLE CITY BLVD_Miscellaneous__ I WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self I I I OF LOS ANGELES BUILDING AND SAFETY DIVISION Ll insure, or a certificate of Workers'Compensation Insurance,or 5 COUNTY ( a certified copy thereof(Sec.3800,Lab.C.). r Policy No. Company FOR APPLICANT TO FI LL IN BUILDIG N ADDRESS Certified copy is hereby furnished. BUILDING y� ` ' AD DR E5 /L�� .�� h� LO LITY ElCertified copy is filed with the county building inspection OCALITY C`Tj NEAREST department. CR'�OSS ST. Date Applicant NEAREST DISTRICT NO. GEtOUP TYPE P CESSED BY CROSS ST. .D _ CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MA'P HIGHWAY STATE MAJOR SECOND LOCAL NO; (CIRCLE) NO. OF BLDGS. (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. 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 o f b u it d in so as to become subject to the Workers Compensation Laws. MAIL ` A OCCUPANCY GROUP AD DR ESS—;;_ —51 , AJp Date Applicant. u l NOTICE TO APPLICANT: If,after making this Certificate of CITY `l ITvo;' 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 I 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. Name of business : PARKING 44 9 SPACES REQ'D D PROVIDED �— I License Number Lic. Class �C/• C- L• _Z730'/%W JJ LIMITED TIME USE- Contractor P a ssi��+� Sc-�iro COritISCtOI Date DATE DATE EJI am exempt from the licensing requirements as I am a I FROM? TO: licensed architect or a registered professional engineer SIZE OFNO.OF. INSPECTOR'S acting in my professional capacity (Section 7051, Bus- I EXISTING BLDG* STORIES SIG ruRE iness and Professions Code). i FINAL APPROVAL Lie.or Reg.No. Date RESENT USE OF BUILDING ✓� /� / 7 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS /,/D (� I FEE ' ON LOT AN- I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi 9/29/0113 ness and Professions Code): I NO. PARKING r, I 1' 1 �• °C I, as owner of the property, will do the work and the SPACES PROVIDED AM 9:59 �'9 structure is not intended or offered for sale (Section 7044,Business and Professions Code). I CONSTRUCTION LENDING AGENCY I ROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency of�)• !/'f, o 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 23 .00 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 25 . 00 upon the above-mention3d property for inspection purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 'CE 8764(1 84) M I SC E L LA N E O U S`APPLICATION I hereby—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 Copt thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BADDREU PR S5 1+ �/ SS � Certified copy is hereby furnished. BUILDING (rr, LO I ALITY ADDRESS. flivd.Certified copy is filed with the county building inspection LOCALITY CROSS T department. Date Applicant NEAREST I DISTRICT NO. I GROUP ITYPEP ROCESSED BY CROSS ST, iD p CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO.OF SLOGS. 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. I certify that in the performance of the work for which this permit is issued,'I shall not employ any person in any manner OWNER a �' y so as to become subject to the Workers' Compensation Laws. MAIL o OCCUPANCY GROUP ADDRESS � ° � � Date Applicant ° !:3 & , TEL• �Ip Z� —�[ D p OCCUPANT LOAD NOTICE TO APPLICANT: If' after mak' this Certificate of CITY No. J1/ 000 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 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 P effect. Te. L phiork PARKING REQ'D PROVIDED ' SPACES License Number Lie. Class 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 NO. OF PROM• TO. INSPECTOR'S acting in my professional capacity (Section 7051, Bus- (EXISTING BLDG. STORIES SIGNATURE inessand Professions Code). PRESENT USE OF BUILDING 1 y FINAL APPROVAL Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTIN BUILDINGS ON LOT AND USE ' o I hereby affirm that I am exempt from the Contractor's D, License Law for the following reason (Section 7031.5, Busi- 1 • • � i i w7� . 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 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING' I hereby affirm that there is a construction lending agency7&-triqo for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. i (9 Lender's Name PROPOSED MAX.OCC. ' 'LendeI'S Address 'ipERMIT FEE 6b I certify that I have read this application and state that the above informationis correct.I agree to comply with all County rER CE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter FEE �� Do upon the above-mentioned. roperty for i pection purposes. — r fl VERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Date