HomeMy Public PortalAbout4504TEMPLE CITY BLVD_Building (2) +wTrw..r.r.rrRrr•�,!F, -.1 _ _. ____ _ ---
WORKERS'COMPENSATION DECLARATION
hereby affirm that 1 havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING d !
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1�-% '--/.
❑ Certified copy is filed with the county building iMpec- BUILDING j�y _/ t�
tion deportment. ADDRESS LOCALITY /
Date Applicant CITY :N ( /� ZIP ' 7 M C OSS ST.A NO OF
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LO 4* S lt7 ?ri.- NOW ON LOTS ��0 G MAP BOASSESSOOK PAGE PARCEL O
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one y� USE ZONE MAP V
hundred dollars(§100)or less.) TRACT BLOCK LOT NO. NO. IZJ
TEL k -t� SPECIAL
I certify that in the performance of the work for which this OWNER NO. CONDITIONS W
permit is issued, I shall not employ any person in any manner DISTRICT I GROUP TYPE FIRE PROCESSED BY >
so as to become subject to the Workers'ComportOti n Lows. ADDRESS CONST. ZONE Q
,Date ,Q A lim l CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO:
/' 1;7j
NOTICE TO APPLICANT:If.aft m lag t E Cert' cote of ARCHITECT OR TEL a
Exemption, you should becbjecf fg the orkers' ENGINEER NO. CLASS NO. DWELL. UNITS_
Compensation provisions oft oy''Co44, you must forth- ADDRESS.' SEWER MAP
ls permit shall be W
with comply with such provisions o?-Ih ~
TEL
deemed revoked. CONTRACTOR NO. BK. PO, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS"" NO VALUATION
(commencing with Section 70DO)of Division 3 of the Business and LIC
Professions Code, and my license is in full force and effect. CITY CLASS E ,
SQ. FT INO. OF NO. OF CHECK
License Number I Class SIZE STORIES - FAMILIES ONE
E n .
Contractor Date DESCRIPTION OF WORK NEW El
ADD ❑ • • • • '
❑ I am exempt under Sec.
FINAL )
$BPf:for this reason — - ALTER REPAIR DATE
USE OF FINAL • : .; i. C .:
Date' EXISTING BLDG. DEMOL
APPLICANT TEL
BY
Signature
OWNER-BUILDER DECLARATION (PRINT) No. `
I hereby off irm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS ► �.f.(, �.
Professions Code): PRESENT
❑ UILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and Y
the structure is not intended or offered for sale(Section LOCALITY .�,.fit�;��- 7) I ry „
7044, Business and Professions Code). MOVING TEL
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
' tion 7044, Business and Professions Code). ADDRESS r�n
M` p �Q
Mfjt
REQUIRED TOTAL SETBACK FROM EXIST. }A /
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LIN WIDTH Pool hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is Issued P.L.
iSec. 3097, Civ. C.). SIDE
P L.
m lender's Name�31C��.tf -S'T Rc Y-'�i K`r/� 64,*-
$ T
- Lender's Address � P.C. Fee E Permit Fee
I certify that I have read this application and state that the Issuance Fee
S above information is correct. I agree to comply with all County Investigation Fee T -
8 ordinances and State laws relating to building construction, Total Fee
d and hereby authorize representatives of this County to enter
upon the above-mentio edrproperty for inspection purposes.
^ "y� �G' n ,. SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant or Agy Oa ms