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Home My Public Portal About6415 TEMPLE CITY BLVD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION {� '1 76 " (11 84) LJ I herby a certfiM that I have a cert mpenficate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers Compensation Insurance,or a certified copy thereof(Sec 3800, Lab C) t-^ Policy No Company FOR APPLICANT TO FI LL IN Coo owesa /J Certified copy u hereby furnished BUILDING /.. ADDR QS¢ S �` (fI�J LOCALITY Certified Copy is filed with the county budding inspection LOCALITY, NQARE¢T department Ests L� G ewoae ST Date Applicant NMA department DISTRICT Icr N o u rYrM o etE¢D By CRO Is ST l/1�• .. _ eonnr.S� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Y COMPENSATION INSURANCE D¢acRIPrIOn LOT No BLOCK :o;/.'�',31G�lCIw DLE1 STATE MAJOR EQCOND LOCAL �,/,yl /PA- �A'A'� �' No OP IS (Thu section need not be completed If the work involved TWt4 Nov oN LOT �jNEfyS USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (f100) or less) 'SE or SS OF Lor��S�LI'D '",TIN. BLDG 1 certify that in the performance of the cork for which this o permit is issued, I shall not employ any person many manner OWNER so as to become subject to the Workers' Compensation Laws MAILST OCCUPANCY GROUP o Date Applicant -Don¢SS J NOTICE TO APPLICANT If, after making this Certificate of clTrsJO�N T91.4-0 OCCUPANT LOAD Exemption, you should become subject to the 1Vorkers' Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE with Comply with such provisions or this permit shalt be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec KnoWl deemed revoked LICENSED CONTRACTORS DECLARATION OCcurANCY INSPECTION 1A Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of DivLuon 3 of the Busr NO OF Q:ITE ness and Professions Code, and my license is in full force and effect PARKING DPACQR RED D D PROVIDEp D License Number Lic Class LIMITED TIME USE Contractor Date DATE GATE FOR I am exempt from the licensing requirements as I am a T. licensed architect or a registered professional engineer INSPECTOR a"ZE STORIES UR¢acting m my professional capacity (Section 7051, Bus- E%ISOOP mess and Professions Code) .f. FINAL APPROVAL PRESENT uaH or BUILDING Lic or Reg No Date CC11'' HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS DG s ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Bus, ness and Professions Code) NO PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Busmen and Professions Code) A 5 9 9 0 A CONSTRUCTION LENDING AGENCY PworaaeD use oP BUILDING I hereby affirm that there is a construction lending agency S # • • • 0 ,30 for the performance of the work for which this permit is I - - 8Q50 issued(Sec 3097,Cw C) Lender's Name PROPOSED MAX OCC • • • 8 0 5 0 d Lender's Address 1 certify that I have read this application and state that the PERMIT FEE Ob 11.20-86 above information is correct I agree to Comply with all County ISSUANCE FEE or inances and Statelaws felating to budding Construction, h by author¢e r r tatwes of this County to enter TOTAL FEE J; bove-meptlon rty for uupection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE re Fermi Date 1 DFP.ARTMNT OF OOUNTY EVi GnMM Building & Safety Division Los Angeles , California ` Records Search Inforuatiob AdBress� A0A 01i, ZU, - Buildi=g ?r-t.'* `7m ssued(D. te) Final 3aspection Description of work Sq. Ft. 36 Buildi=g Pzt.# 916 6 Issue (Date) F'.aal Inspection 6 za Description of work Sq.Ft. gx 3�� BuiiZirg ¢t.1J• Issued(Date) Final Inspection Description of work . Sq. Ft. Building r t. Issaed(Date) Final Inspection Description of work • Sq.Ft. Building ?=--# Issued(Date) Final Inspection Description of word 6q.Ft. Building ?zt.# Issued (Date) Final Iaspec:ion__ Descriptioz of work 77 Sr. Gjerx , COUNTY OF LOS ANGELtb DEPARTMENT OF COUNTY ENGINM BUILDING i SAFETY DIVISION ' t , 6908 K KouFlmon Avenue ' Twneb CNv, CalifewMe