HomeMy Public PortalAbout6346 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 8754"
(2 MISCELLANEOUS APPLICATION
1 heresy affirm that I have ceof consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof f6ec 3800 Lab C)
Policy No Compan) FOR APPLICANT TO FILL IN wUILDFN
❑ D DRESS
Certified copy B hereby furnishedBInLDINa LOCALITY
❑ woowENs T � y I
Certified copy Is filed with the county building Inspection NEARHAT
department LOCALITY CROSS aT
Date Applicant NEAR ear DIST Crj�/ a u rvre PRoc s o r
CROaa 8T (,LI -e �r /t jt CONS
CERTIFICATE OF EXEMPTION FROM WORKERS L¢awL V V
COMPENSATION INSURANCE 00SCRIPT1ON LOT NO BLOCK MAe w6Rw j
N. (CInCL6) STATE MAJOR aHCO LOCaL a
NO OF BLDaa
(This section need not be hndredcompleted ll the work involved TRACT Now ON Lor u¢p zon¢ ar¢nwL CONDITIONS ]CJJ
by the permit u for one hundred dollars ($100) or ILss) K
UAH OF
TI
SIZE OF LOT H%ISTINO BLDG Q
I certify that in the performance of the work for which this Q
permit Is Issued 1 shall not employ any person In any manner OWNER FT-73
� U
so as to become subject to the Workers Compensation Laws MAIL /� tl OCCUPANCY GROUP W
ADDRESS P..r) , `9'L ' d
Date Applicant // U)
NOTICE TO APPLICANT If after making this Certificate of CITY C Trio kp OCCUPANT LOAD
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth APPLICATION FbR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION
deemed revoked ❑ ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BML..) No or axlra
9 (commencing with Section 7000) of Division 3 of the Bus,
ness and Professions Code and my license Is In full force and ^ PwRxINa
effect wPACES eQ'D PROVIDED
PARKIN
License Number Lic Class 1&.. Q- fJA&kJJLUj
LIMITED TIME USE
Contractor Date DATE DATA
❑ •AOM To
1 am exempt from the licensingregiregistered
requirements as I Em a
I
architect or a registered professional engineer SIZE or No OF INSPECTOR E
acting In my professional capacity (SeCYIOD 7e$1 BUS- EXISTING BLDG 9TORIEE GN ATURE
(ness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date
HOML OWNER BUILDER DECLARATION No of ENo UNG euicolNCS
ON Lor AND LIGE :14455A
1 hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Bust # • • • • 3 0
ness and Professions Code) 'NO PARKING
PACES PROVIDED
❑ I as owner of the property will do the work and the 1 - - 8(150
structure is not Intended or offered for sale (Section '• - • • • 8 0 5 0 LTi
7044 Business and Professions Code)
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY .,o 4 17-86
I hereby affirm that there Is a construction lending agency -
for the performance of the work for which this permit Is
issued(Sec 3097 Civ C)
Lenders Name
PROPOSED MAX OCC
Lender's Address PERMIT IEE • `
1 certify that 1 have read this application and state that the
above Information Is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to budding consiructlon TOTAL FEE
End he thanzereprese 1 of this County to enter
upo he a ntentyryed ctlon purpose SEE REVERSE I OR EXPLANATORY LANGUAGE
(G;.! ,/
Signature of Permittee Date