HomeMy Public PortalAbout4331 1/2TEMPLE CITY BLVD_Building (2) WORKERS'COMPENSATION DECLARATION
' sufe,o a""" """ 'tee r certificate Comp of Coigea10 "if APPLICATION FOR BUILDING PERMIT �;
Insure, or a tertifkote of Workeri Compemotbeu Insurance,
Or a certified copy thereof(Sec. 7800, tab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
�t Policy No. Company
❑ /Certified copy Is hereby furnished. FOR APPLICANT TO FILL IN
f-Y CMifled copy U filed with the county building inspec- gDppp,t0 ��/ , -y
IIGI dipm ant. A00RES5
Date Q`-/- 9s Apptkont err a.FT nv 4/7Ba ,per,,.,
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NNO.OF OW BLDG& 5T.
COMPENSATION INSURANCE
hundred dollars 0100)is sedlon need not w Iw.)plated if the permit b for one TRACT 111001 OT NO. =505 0 1 PACE PARCEL
TEL A 115E ONE
1 certify that in the performance of the work for which this 'd &QAMJAfJ0 NO I NO.
Permit is[awed,I shall rot employ any"n In any manner 23y �2 SPECIAL
so 01160 become subject to the Workers Compensation Laws. CONDITIONS
Doo CITY La /D A zip / O 1�
NOTICE TO APPLICANT:M, after making this Certificate of AROIRECT OR �- NSU. DISTRICT G11" TYPE FIRE BY v
Exemption, you should become subject to the Workers' /)ry a*w O
Compensation provisions of the Labor Code, you must forth- ADDRESS s 3
with Comply With such provisions or this permit stall be
deemed nonsked. CO/NIRACIOR TK 77 STATISTICAL TION API.
UCENSM CONTRACTORS DECLARATION CLASS NO. DWEIL UNITS_
1 hereby affirm shot I om licensed under provisions of Chapter 9 ADORFSS SIC7vou 5r Na'7��00 3
(oommerxdrg with Section 7000)of Division 7 of the B firms and uG SEALER MAP
Professions Cade,and my license is in full force arld affect. CITY (.QLt/ N ec w. VALWAT10N
Z O d'3 y G 3 /
10.FT No.OF NO.OF CHECK
License Number. Lk.Class sin Q�� STORIES IFAMJUES ONE
VALLWAMM
c
Canaoctor pate DESCRIPTION OF WORK NEW
❑1 am exempt under Set7/v Aso $
ALTER
B.BP.G far this reason 0 w b oA REPAIR $
Dols` Ei WrN elnG. DEMOL �E 01 7 a 1 A
Signal re OWNER-SUILDER DECLARATION n" T L/NS t 0.33/- rfS/ OAmm`�-`/✓
I IuerebY
off Inn that I oat exempt from the Contraclors Litems 67r)/� (;( � ST' Pv )
Law for the following mason (Section 7071.5, Business and 1 1 S 5 0
Professions Code):
BU
❑ 1, as owner of the property, or my employees with ADDRESSILDING • • 1 1 5 5 0
wages m ths[r sole compensation,will do the work and ,A /a s� 04.02-85
ter smuture Is not intended or offered for sale(Section '`4
70",Business and Professions Cade). MOVING TEL /1 /
❑ 1,as owner of the property,am eulusively contracting CONTRACTOR NO.
with licensed controcton to construct the projea (Sec- ADDRESS
tion 70", Business and Professions Codec
CONSTRUCTION LENDING AGENCY E`j;Z&rERrMYMAW.D7I HWY I TOTALPROP.5ETBACK FROM TA
hereby _
I heby affirm that there b M
a construction lending agency far FRO
LINE
the Performance of the work far which this permit is issued P.L.
(Sec 3097. Civ. C.). SIDE
B P.L.
Lenders Name
i) LDMA RN. 8
Lender's Address P.C.M S Permit F» 1 U
I certify that 1 how rood this application and state that the issuance FSI. Q PW~Fm e
` abuse information is corsets. I cgs"to comply with all County Investigation Fw
®$ ordinances and Stere laws relating to building construction,
Total FewIMM Perm,t
and hereby r of this County ropresenlolives toenter
pS$ the nt property for Inspection purposes.
—4411^ Am,,O 4-7-- S_J fit FAVI FOt EXPLANATORY LANGUAGE
or Agent Date