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HomeMy Public PortalAbout5952 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATIONI CE 875(2-80) fill I SC E L LA N E®U 6 APPLICATION CE 875 I hereby affirm that I have a certificate of consent to self COUN'T'Y OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company 19 FOR APPLICANT TO FILL IN BUILDING PA� ADDRESS ❑ Certified copy is hereby furnished. I UILDING /�J, LOCALITY f ❑ OR SS SA M �• Certified copy is filed with the county building inspection If NEAREST department. I LOCALITY CROSS ST. Date Applicant i NEAREST DISTRICT GR UP PE ROCE SED BY CROSS ST. I CONST. CL CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE i DESCRIPTION LOT NO. BLOCK MAP R16RWAY �. No. iCIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed if the work involved I TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for one hundred dollars ($100) or less.) USE of ZE OF LOT EXISTING BLDG. �'� X I certify that in the performance of the work for which this Q permit is issued, I shall not employ any person in any mannerWNER so as to become subject to the Workers'Compensation Laws. I OCCUPANCY GROUP 1%.A I LLI� Date Applicant /� �pj G NOTICE TO APPLICANT: If, after making this Certificate of TTY�ETLl� (iJ NE. G�f���7 OCCUPANT LOAD � Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensatidn provisions of the Labor Code, you must forth- with comply with Such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. i ❑ Cl No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter I SAFETY PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS ❑ 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code,and my license is in full force and PA.RKING eVect. I SPACES REQ'D E= PROVIDED }l License Number Lic.Class I LIMITED TIME USE Contractor Date 1 DATE DATE ❑ FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer 1 SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. S�TO/RIES SIGNATURE ) r-J inessand Professions Code). PRESET USE OF BUILDING FINAL APPROVAL c P Lic.or Reg.No:. Date NO.OF EXISTING BUILDINGS HOME OWNER-BUILDER DECLARATION 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 SPACES PROVIDED❑ p n /' &O n I, as owner of the property, will do the work and the Y 4 !1 structure is not intended or offered for sale (Section �J y� 7044,Business and Professions Code). D D D D 8 8 PROPOSED USE OF BUILDING /r CONSTRUCTION LENDING AGENCY I o 0 0 0 0 0,0 I hereby affirm that there is a construction lending agency I for the performance of the work for which this permit is 0 1.28-83 issued(Sec. 3097,Civ.C.). 1 Lender's Name i PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the I ISSUANCE FEE above information is correct.I agree to comply with all County ordinances and State l building construction, TOTAL FEE and her thorize re pr a tatives of this County to enter pon t bo e-mentioned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignatur Permittee Date (' I WORKERS'CUMMhMA11UN 1JCl.LAKA11U1V1 20-0063DPw12/90 l�l�+)k.IL..."L. ,R N=VVI I I hereby affirm•that I have.a certificate of consent to self COUNTY OF LOS'ANGELES I, BUILDING•AND SAFETY DIVISION _ •uinsure,or a cerMfieate of Workers'Compensation Insura ice,or _ ;� , _ 'a certified•copy thereof(See 3800, Lah C.),' (� I Policy'No. __Company FOR APPLICANT TO FILL IN BUILDING ' 1. t BU L I G ADDRESS ADDRESS ❑ ,Certified copy.is here' furnished g CtU)(,. i LOCALITY { I ❑ Certified copy is filed with the county building inspection CITY �w _. ZIP I department. 45M L45 C-) 91?r a ?,O fb NEAREST CROSS ST. ' Date Applicant SIZE OF LOT NO.OF SLOGS.NOW ON LOT DISTRICT NO. GROUP TYPE I PROCESSED BY CERTIFICATE OF •EXEMPTION FROM WORKERS' -2--5D coNsr. TRACT BLOCK LOT NO. (' 1 AY COMPENSATION INSURANCE NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work inv lved ASSESSOR MAP BOOK PAGE PARCEL C by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS TEL NO. t L certify that in the performance,of the work for which this b uwne tA b VA&b � g`7�ISAI permit is issued:T§hall not employ any person in any manner I so as to become subject to the Workers' Compensation Laws. ADDRESS �(f� u 5 OCCUPANCY GROUP ( Date Applicant . NOTICE TO APPLICANT: If.' after making this Certificate Cry L� C•l zIP )��a �w NOCCUPANT LOAD of Exemption. you should become subject to the Workers' APPLICATION FOR Compensation provisions of the-fAbor Code.you must forthwith EXIT HARDWARE: comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ revoked No Spec.Knowl. ❑ ' ' OCCUPANCY INSPECTION Panic Devices ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) { I 9(commencing with Section 7000)of Division 3 of the Business me o usluess NO.OF EXITS and Professions Code,and my license is in full force and effect. -I� License Number L)c.Class AIk2UA0J6 'J PARKINISPACESG• REWD = PROVIDED ( I I Contractor Date 1\ I LIMITED TIME USE I ❑ I am exempt from the licensing requirements as 14m a DATE DATE licensed architect or a registered professional engineer FROM: To: acting in my professional capacity(Section 7051,Business SIZE OF NO.OF INSPECTOR'S '(`• I and PIOfeSS10nS Code). EXISTING BLDG. ✓� STORIES SIGNATURE. Lic.or Reg.No. Date PRESENT USE OF BUILDING AVYDCAU.XJM SAL165 QdWl,t 0FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE 1 I hereby affirm that I am-exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ( I i Professions Code): No.PARKING SPACES PROVIDED ❑ I, as owner of the property, will do the work and thelow structure is not intended or offered for sale(Section 7044,1 PROPOSED USE OF BUILDING Business and Professions Code). ( ISAX413 ` LUYL. S' �LC55 8(Uu� I CONSTRUCTION LENDING AGENCY .... I hereby affirm that there is a construction lending agency for the performance of the work fol' which this permit is issued (Sec. 3097,Civ.C.). PROPOSED MAX.OCC. , Lender's Name A TEL NO. L%`Jj `WL ) 72 Lender's Address ADDRESS iI certify that I have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE I ordingnces and State laws ielating to building construction,and <. hereby authorize representatives.of this County to enter upon ISSUANCE FEE R the above-mentioned property for inspection purposes. TOTAL FEE $ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 1