HomeMy Public PortalAbout5345 PAL MAL AVE_Building_11/17/1988WORKERS COMPENSATION DECLARATION
11880449 SB
hereby affum that I have a certificate of consent to self APPLICATION FOR BUILDING PERMITinsurearocertificateofWkersCompensationInsurance
or a certified copy thereof (Sec 3800 Lob C )
Poh< No W0007146
COUNTY OF LOS ANGELES BUILDING AND SAFETY
y Company Raavar Tnc
Certified copy is hereby furnished FOR APPLICANT TO FILL INDINESS
Certified copy is filed with the county building mspec BUILDING
tion department ADDRESS 5345 PAI MAI
Date 7-1-89 Applicant Virgin Rnnf rn CITY Temple City ZIP 91780 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST
This section need not be completed if the permit is for one
TRACT BLOCK LOi NO
ASSESSOR
hundred dollars ($100)or lass )
T, USE ONE
I certify that in the performance of the work for which this
OWNER NO NO
permit a Issued I shall not employ any person in any manner
ADDRESS SPECIALPONSsoastobecomesubjecttotheWorkersCompensationLaws
7--'
5ff
Date Applicant
Cltt ZIP 8t
NOTICE TO APPLICANT If, cher making this Certificate of
ARCHITECT OR TEL DWRICT UP
S_
j Z SSED BY O
Exemption you should become subject to the Workers rr
T' //
Compensation provisions of the Labor Code, you must forth- ADDRESS
cU
V
with comply with such provisions or this permit shall be
TEL STATISTICAL CLASSIFICATION APT
at
deemed revoked CONTRACTOR Virgin Roof Co. P40287-0507
LICENSED CONTRACTORS DECLARATION LIC OA55 NO DWELL UNrm_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS P.0. Box J160650
commencing with Section 7000)of Devaion 3 of the Business ord LIC SEWER MAP
Profusions Code and my license is in full force and effect CITY San Gabriel CLASS C39 BK PG VALIDATION
SO FT NO OF NO aF CHECK
License Number 160650 Lec C(on CR9 sin STORIES FAMILIES ONE
VALUATION
Contractor Virgin Roof CO- Date 6-30-89 DESCRIPTION OF WORK Tear off flat area NEW
900.00
I am exempt under Sec the a 1 #28 #11 and ca she t
R
Pilo.
B dP C for this reason REPAIR
Date USE OFEXISTING BLDG DE/J OL
Signature TEL FA
APPLICANT
L /
OWNER BUILDER DECLARATION
PRINr Virgin Roo NO
DAT
I hereby affirm that I am exempt from the Contractor a License
Law for the following reason (Section 7031 5, Business and ADDRESS ETN 1 0%a 2 A
Professions Code) BT
I as owner of the property, y employees
BUILDING
or m em to ees with ADDRESS
wages as their sole compensoteon,will do the work and
the structure is not intended or offered for sale(Section LOCALITY I • e40,50
70", Business and Professions Code) MOVING TEL
4 0 rJ 0I, as owner of the properly, am exclusively contracting
TRACTOR NO o
with licensed contractors to construct the project (Sec-
ADDRESS
tion 7041 Business and Professions Code) o928-88
CONSTRUCTION LENDING AGENCY SET
UED CK FROM
BACK YARD HWY TO APROP LINE WIDTH
I hereby affum that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P L
Sec 3097 Civ C ) SIDEPL
Lender s Nome
8LDMA Ref I
Lender's Address PC Fee f Permit Fee
I certify that I have read this application and state that the Issuance Fee LDMA P/C 1
above mformateon is correct I agree to comply with all County investigation Fee
S ordinances and State jaws relating to building construction,
R and hereby authorize representatives of this County to enter
Total Fee LDMA Parm R
a upon the obove-menho ad property for inspection purposes
octmX9-22-88 EEE REVOKE FOR EXPLANATORY LANGUAGE
Ir
lure of Applicant or AgentApplicantor Agent Date