HomeMy Public PortalAbout5957 TEMPLE CITY BLVD_Miscellaneous__ I
r WORKERS'COMPENSATION DECLARATION 76M444
ICE 875(11.84) MISCELLANEOUS APPLICATION
1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BIUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company— FOR APPLICANT TO FILL IN nn)i.I.L y
49
Certified co is hereby furnished. BUILDING y.r,/ �`F �� �L� J�
Py y
XX ADDRESS 51 LOrA LITY
Certified copy is fried with the county building inspection LOCALITY NEKREST
department. CR RISS ST.
Date Applicant NEAREST 1�� 011-TRIC NO GRO P TYPE ��' P CESSED BY
CROSS ST. WOOGLtill FI I PNO CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL F YY_
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ,11011w AY STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USF,
ZONE SPEC ADLpCO NDITIONS
by the permit is for one hundred dollars ($100) or less.) use OF /J
' SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this oma',
permit is issued,1 shall not employ any person in any manner OWNEROf bulldin -
so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS Li�6� •/Imo'
Date Applicant
104
NOTICE TO APPLICANT: If,after making this Certificate of CITY NO. I OCCUPANT LOAD uj
Exemption, you should become subject to the Workers' APPLICATION FOR L'XIT 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. ❑ I OCCUPANCY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION
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 anix
effect. Name of business PA Es
KING RRQ'D PROVIDED
S
License Number Lic.Class f S �Y10 o C�rl~a1(M(m4�� SP C
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a
PN¢MI TO:
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 1 s N u E
iness and Professions Code). FIkAL APPROVAL q
Lic.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS V
ON LOT AND USE
1 hereby affirm that I am exempt from the Contractor's JI'� 1]000—[l00 i 1.21
License Law for the following reason (Section 7031.5, Busi- Z- '�•'-''''
I � n�cC
ness and Professions Code): NO. PARKING i
Z
I, as owner of tete property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section i
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PRoroseD use OF BUILDING
I hereby affirm that there is a construction lending agency 6etQ1 nr=1 + 2qEiT4A11 yL�
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
1 certify that 1 have read this application and state that the PERMIT FEE
25.00
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State 1 ws relating to building construction,
and hereby authorize re ntatives of this County to enter TOTAL.FEE 25.00
A •I upon 1e above- enti ed roper�y for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE
x. xx[7-3D-9(p
.'` Signature f e nrittec Date