HomeMy Public PortalAbout4500-4502-4504-4506TEMPLE CITY BLVD_Building (2) .l V ORKERS'COMPENSATION DECLARATION
-rniu�e�'orau�nfFmtteahave a
of Compensation tnsutran al` - APPLICATION FOR BUILDING PERMIT Il
a cdndled Copy thereof (Sec 3800, Lab C ) I _ I -
Policy No Company
COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Certified copy n hereby furnished FOR APPLICANT TO FILL IN 14L nooaESS
Certified copy is filed with the county budding aspec- BUILDING ys NgO2-/ tl
tion department ADDRESS f / LOCALITY
NEAREST
Dote Applicant CITY fN ZIP CROSS Si
CERTIFICATE OF EXEMPTION FROM WORKERS 11F NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOTx NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollan ($100)or less ) TRACE Bloat LOT nIo N 2a!
TEL �� SPECIAL
I certify that m the performance of the work for which the OWNER NO — CONDDIONS d
permit is Issued, I shall not employ any person in any manner �r DISTRICT GROUP TYPE FIRE PROLE BY O
so as to become subject to the Workers Compen ate n ADDRESS mf Cs/T(/ CONST / ZONE U
�7 �O �s 5 VQ i )- V � IM
Date `" � Applic I CITY Ly ZIP o STATISTICAL CUSfIF TION APT O
NOTICE TO APPLICANT If, aft m I th Cert c to of ARCHITECTNO Y) CLASS NO DWELL UNITS_ W
Exemption, you should bet a ect o the orkers' ��.}-- G
Compensation provisions of t C You must forth- &DDE55 nV/Ar SEWER MAP N
with comply wish wch proves ons is permit shall beZ
deemed revoked iRA / SK SPG VAUDATION i
LICENSED CONTRACTORS DECLARATION / LIC '
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE /F 0& NO VALUATION
(cornmeniang with Section 7000)of Division 3 of the Business and LIC m
Professions Code, and mylicense n In full force and effect Cm�E/� fi CLASS
50 FT jC054 INO OF I NO OF CHEIX
License Number Lic Class SIZE STORIES Z FAA4UE5 ONE 2 2 2 Q A
DESCRIPTION OF WORK / , NEW $ ,
Contractor Dote ADD # • • • • 2 3
ElI am exempt under Sec j /
ALTER O Orsi L `� -Zo/ - 11 34Q66
B&P C for this reason ' REPAIR
Date EXIS LNG BLDG NI —f DEMOL Q By FlN _ • 1.34Q66
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Signature APPLICANTf L '17N L
M 0 6 iJ 7-8 5
OWNER BUILDER DECLARATION PRI / '
I hereby affirm that I am exempt from the Contractors License t X7 .50 �r ► ;22221 A
Law for the following reason (Section 7031 5, Business and ADDRESS
Professions Code) PRESENT
# 1
• . .
1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation will do the work and I 1587 7 5
the structure Is not Intended or offered for sale(Section _ LOCALITY _ _
7044, Business and Professions Code) MOVING TEL
1, as owner of the property am exclusively contracting CONTRACTOR NO - Y e 1.587.756
with licensed controctors to construct the project (Sx- ADDRESS
tion 7044 Bustness and Profewons Code) _ 0607-85
RE IRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SEM
BACK YARD HWY PROP LINE WIDTH r i
I hereby affirm that there is a construction lending agency for FRONT ► ' �. __ _ _ ..
the performance of the work for which this permit Is Issued Pl.
r'
Sec 3097 Civ C ) SIDE
S _
� Lenders Name /pL
gLender s Address 6 PC Fe•f U 46 Permit Fee1. 5712-S
I certify that I have read this app non and state that the hsocince Fee I ,
above Information Is correct I agree to comply with all County Inveglg rn.Fee
ordnance• and State jaws relating to building construction,
and hereby authorize representatives of this County to enter Toiml F••
upon the abovemenho ed rojseny for inspection--! purposes
1
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