HomeMy Public PortalAbout6000 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8754(1 1-84) MISCELLANEOUS A P P L I C A T I O N
I hereby affirm that I have a certificate of consent fself �. COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or'a certificate of Workers'Compensation Insurance,
e,or
a certii'ted cop$thereof(Sec.3800,Lab.Q.
Policy.Wo. Company FOR APP LI CANT TO FILL IN BUILDING �11- r1
ADDRESS , 1,19 V
Certified copy is hereby furnished. VAN
oOD_ 0DQ' 7' CII LV LOCALITY
OO L�
Certified copy is filed with the county budding inspection ��G`� I NEAREST
department. I��L� C lCROSS STDate Applicant DISTRICTNO. GROUP TYPE PROCESSED BY
CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE ON LOT NO. BLOCK MAP MIG MW AY STATE MAJOR SECOND LOCAL NO. (CIRCLE)
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL 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 C�
permit is issued,I shall not employ any person in any manner OWNER VAM
so as to become subject to the Workers' Compensation Laws. MAIL1 V OCCUPANCY GROUP a
ADDRESS J1`1M.o�JDd E5
Date Applicant W
NOTICE TO APPLICANT: If, after making this Certificate of , No1.' OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. [J ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPBCTION Panic Devices D
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- s NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. i lj<Y PARKING
SPACES REq'D PROVIDED
License Number Lic. Class I LIMITED TIME USE
Contractor Date "\J DATE DATE
I am exempt from the licensing requirements as I am a
FROM: TO:
.licensed architect or a registered professional engineer gIZE OF NO.OF INSPECTOR'S
SIGNATURE
acting in my professional capacity (Section 7051, Bus-
iness BLDG,and Professions Code).
RESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
_NL V k I
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- NO FEE
ness and Professions Code): i NO.PARKING
F] 1, as owner of the property, will do the work and the SPACES PROVIDED,
structure is not intended or offered for sale (Section
7044,Business and Professions Code). � 0������1 �f��J�av�
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 5746 PM 049
I hereby affirm that there is a construction lending agen �L U XI
for the performance of the work for which this permit is ,,OiP�r
issued(Sec.3097,Civ.Q. —�
Lender's Name I
PROPOSED MAX. OCC.
Lender's Address O0
PERMIT FEE <
I certify that I have read this application and state that the J
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinapces and State laws relating to building construction, b�
and here y authorize representatives of this County to enter TOTAL FEE
o 't above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
"�JSignature of Pe ttee Date
)