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