HomeMy Public PortalAbout4505TEMPLE CITY BLVD_Building (2) APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES . ' BUILDINGANDSAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILLIN BUILDING ADDRESS
I heroby affirm that I hale a certificate of consent to sell Insure BUILDNG ADDRESS ,A
or a cerbfrka
icate of wbre Compensation Insurance or a candied !/ $ 05 r"AlE C/1 g(,
copy thereof(Sec 3800 Lab C) �L GITy /�po
L / U LOCALITY
��No ConTiPe<ry SIZE OF NO OF BLDGS NOW ON LOT TEN CE Ica
\
❑ Certified Copy is hereby famished 6/Do NEAREST CROSS 57
❑ Certified copy o filed with the County budding vispedlon TRACT BLOCK LOT NO 14 -,j Z
department!department! (2 y 2 USE ZONE MAP NO /44 2
IDate Applicant ASSESSOR 5 BOOK PAGE DO RiRCELO�f^ /t SPEC41 C01311TgNS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER •C1� TEL
r'1D !P If /`
COMPENSATION INSURANCE ry 6u P C WTHW toxo FT OF SCHOOL? YES NO
(Thom section$1D need fid be completed d the PeTrrst®for Ono hundred ADDRESS'S T51 B s r
DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
differs(E 100)or Ie9B)
I candy that In the perlonnumce d the work for which this permd ^ CITY
Is ISSN I shay not employ any Penson in any manner so as to
become subject to the Workers Campen cation LBWS ARCHITECT CA ENGINEER TEL NO
STATISTICAL CLASSI)CATION APT CONDO
Date Applicant \ ADDRESS CLASS NO 11 / DWELL UNITS
M077CE TO APPLICANT If after makag the Certificate of REOUIRED TOTAL SETBACK FROM EXIST
Exemption you should become •subject t0 Ute workersCONTR� C Q[ TEL NO SET BACK YARD IMAY PROP UNE WIOTR
m
Compensahprowsons of the Labor Code you must forthwith TL
FROM
Comply with each proyrepns or this permit shall be deemed ravplcetl ADDRESS LIC NO PL
LICENSED CONTRACTORS DECLARATIONSIDE
CRY LIC CLASS P L
I hereby affirm that I am licensed undsrprowspns of Chapter ,
(cpTnmefping with Section 7000)Of Drvmbn 3 d the Business end SO FT SIZE NO OF STORES NO OF FPMIUES NEW ❑ BKR� �0
Professions Code and my license Is In lull force and effect ] PO
License,Number Lc Close DE RIP F NORK ADD ❑ cw�LUAn�tON ,
Contractor Date K a/Z ALTER ❑ sJ,*i ��� o
❑ I am exempt under Sec _7 L REPAIR ❑ $ z
BAPC for the reason \ l _t<=s�-��� DEMOL ❑
OF E% NG BLDG LOMA P/C
Date URM ❑
Signature
TEL NO vis LOW Perm 0 _
AI as owner of the property or my employees with wages as 6115Al 9161 ' O z
their Bale cpmperisatKm will do the work and the structure is (ADDRESS i0 ' •� AA
rpt Intended or offered for sale (Section 7044 Business and HUtL�S S /1 FlruLProlessons Code) A ER TIwN TIE❑ I with
licen Owner d the property ant excthe proje L Sect n 44AI,rpLNTg a CFIED W TIE II/SARDxua 61AMRPLa YFpMMDoN oiji0i FlNAL •� +
Business
contractors o Code) the project ISectpn 7044
Buelreee aro Professions coda) YES❑ NO❑ • TI)TfIL Lgr . -30
wl1 TIE nNDIED usE OF TRE GONST BY TIE AwLlCexr OR FurUE sl301 --
�-• CONSTRUCTION LENDING AGENCY COAST M REOURE A fERMR FOR SIRS T(SCA OF uE MBIA I N Q CH P*301 sr FOR l \ + `-j{Ft_
COAST AoV OWIfTV WNADEIAEM ge1gLT ISCAo1.0)9EE f£nIIr1No CIECKLtaT FOR
!
GUIDELINES
I e eaffirm that there e o construction lending agency for v s❑ Noll
3097
•QUI
u the performance
d the work for which this Permit m Issued(Sec 01411 w TIE NAZArpouswr,T QR WiarwwTaNOL AND TIES S COUN'ry CODE
ry 3087 Cr, c) CHEba1ST I IROERSTNID MY REGUFIEI.ENTS IRAER ME LOS ANDELES GOLWTV COPE
g Lender s Name W RA a RERE EPO mmq N aC iOm Oa NA g AR F pM 9CN W I I113c—i30131
$ LendersAddrosa wEsro .T 4911 i AM S`:1.
0
I cer fy that I have read this aWicatlorn and state under penalty
g of perjury that the above mformatlon is Correct I agree to contPhA PC FEE PERMIT FEE I,n
R with as county ordinances ws and State larelat4 p budding
S coraft on and hereby authonze representatives of this County I,,SWNCE FEE
g m
to ter upm � arty for irap-ecapn r
.1" /A�
� lNESTIGATM FEE TOLL FEE �O
w.>n a PCZ+ y
SEE REVERSE FOR EXPLANATORY LANGUAGE