HomeMy Public PortalAbout4504TEMPLE CITY BLVD_Building WORKERS COMPENSATION DECLARATION �1 `
,,insure,uroi'eby 'cnrtifiate f Workers'have a Compensations Insurance, APPLICATIONFOR- BUILDING PERMIT lI IS
orl:ffrfxed,oppy,�mI ift 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olliicy No`1 tt5544/ 7 3lCobm�pany Ohio Casualty Co.
BUILDING
Certified copy is hereby furnished FOR APPLICANT TO FILL IN - ADDRESS 4456 Temple City Blvd.
® Certified copy is filed with the county building mspec BUILDING
tion department _ ADDRESS 4456 T le Cit Blvd. _ LOCALITY IT le Cit
Date 10-4-84 Applicon1augh]-Tn CorWcation CITY JiggpleZIP 91780 CR=STT E. Jower A7.ilqA Rand
ASSESSOR
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT60 X 206 X 64 �pj Lp'j3 1 house MAP BooK #264 IPAGE 24 25 PARca 24
i COMPENSATION INSURANCE
(This section need not be completed if the permit is for one TRACT 12998 BLOCK LOT USE ZONE NOP Xe)dollars(f100)or less ) SPECIALIf
Y
I certify that in the performance of the work for which this OWNER Town & Court Ind 'N0'442--9328 R-4 CONDITIONS d
permit s imed I shall not employ any person in any manner - DISTRICT GROUP TYPE FIRE D BY O
so as to become subject to the Workers'Compensation Laws ADDRESS9608 E. Lower Azusa Rd. CONST ZONE U
t�"D$ R-3 ✓ W
Date Applicant ARma1I Tcr le Cit zlv rEL 91780 STATISTICAL CLASSIFICATION 3 APT CON �
NOTICE TO APPLICANT If, offer making this Certificate of
Exemption, you should become subject to the Workers I'' NO CLASS NO DWELL UNITS
Compensation provisions of the Labor Code, you must forth ADDRESS - - SEWER MAP N
with comply with such provisions or this permit shall be Z
deemed revoked coNTRACT&H in CorporatiORi -7414 BK PG VALWATION
LICENSED CONTRACTORS DECLARATION LIC
I hereby affnm that I am licensed under provisions of Chapter 9 ADDRESS eSS NO VALUATION
(commencing with Section 7000)of Division 3 of the Business and UC
Professions Code,and my license is in full force and effect CITY Rancho Q1C8RT0 a CLASS B $ ►
License Number 446338 Lec Class B SIs`ZE"1400 STORIES 1 FFAAMI°ES 1 CONE '
Conaactar La`g"lin Corporat n 10-4-84 DESCRIPTION OF WORK Denro sh ex sti " ❑ L
Elt tun ecce t swim- 1 ADD ❑
1 am exempt under Sec TER ❑ FINAL
- -
B dP C for this reason CAncrete. � REPAIR ❑ DAT!
Data USE OF
EXISTING BLDG R-1 Residence DEMOL (}� FIN
Signature Ate " in Co rationIL By 3 0 8 3 3 A
OWNER-BUILDER DECLARATION Ines$ Center n��NrO e e e e e
I hereby affirm that I am exempt from the Contractor's License ESS Cho 6 Cent a a 91730 ► # l
Law for the following reason (Section 7031 S' Business andim
-
Profsssiom Code) I e - 6Q50
ADDREBUILDING 4456 T le Cit Blvd. .
I g owner of the property, or my employees with ADDRESS I e e - 6(1506'
wages ct their sole compeintended
off well f o the work tion LOCALITY
the structure m not mrondrd or offered for isle(Section -' - 1 G05-84
lou, Business and Professiprop",
m Code) '�W"G gabomas House MoversFN 6 2-8313
1, as owner of the property, am exclusively con ac mg - -
with licensed contractors to construct the project (Sec- ADDRESS , -
tion 7044 Business and Professions Code) _
CONSTRUCTION LENDING AGENCY '� YARD IIWI' TOT�CK FROM INE WIDTH
S
1 hereby affirm that there is a construction lending agency for FRONT ►
the performance of the work for which this permit is issued P L
ZSec 3097 Civ C ) SIDE _
P L,
Lenders Nome None
Lenders Address N/A P C Fee f Pmmn Fee /
Od
• 1 certify that I have read this application and amts that the lau°nce Fee Q f
above mformar los s correct I agree to comply with all County nvesirgoaon Fee _
ordinances and State jaws relating to building construction, ToWl Fee n S6
and hereby authorize repreaa avec of this County to enter
u o- endo for inspection purposes
^ -10-4-84 SU RIEVBL[FOR EXPLANATORY LANGUAGN _
Sq o plnt a,A ent) pale esamq r'ey