HomeMy Public PortalAbout4824TEMPLE CITY BLVD_Building 1 ,
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILD: Ess
1 BUILgNG ES91
I hereby affirm that I have a certificate insure of consent to as" 77WP4E c-2Z
or a certificate of YAxkem Compensation Insurance Or a cerhfed CITY Z1P - -
copy thereof(Sec 3800 Lab C) I rLWPzC iii LOCALITY
1
Policy No Company' SIZE OF LOT �+/ NO OF M DOS NOW ON LOT
❑ Cerbfed copy is hereby fumshed NEAREST CROSS ST
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO
department USE ZONE MAP NO
Data Applicant ASSESSOR AMP 8001( PAGE ixt1l
SPECIAL CONDITIONS ,
CERTIFICATE OF EXEMPTION FROM WORKERS' ayr� ^ G/ '
COMPENSATION INSURANCE MR)f —OAT WITS 1000 FT OF SCHOOL' YES No
(This Section need not be completed d the permit is for one hundred ADD I
�.' G� ,, DISTRICT GROUP CONST FIRE ZONE ESSED BY
dollars ($100)or less) Crtv / LP a'Da 3
I certify that m the perlumarpe of the work for whxYl the permitrrmpzir
Is Issued I shall not employ arty person In arty manner so as to ARGiITECT OR ENGINEER NO
become subject to the Workers Corn born SPTISTICAI CLASSIFtGAT10N APT CONDO
•—fry! / C113S NO �p/S /_ gNELL 11H IS
NoTrEA �T If y ADDRESS
Exerni t RJ 1 !YT b Aker m subject
the Certificate Of REQUIRED TOTAL SE K FROM IDT
Exemplwn you should became sub)ect to the Wodsere CONTRACTOR TEL ND BET RACK vPAD FAYY PROP LINE
WIDTH
Canpensatan provisions of the Labor Code you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO PL
LICENSED CONTRACTORS DECLARATIONSDE
CITY LIC CLASS P L
I hereby affirm that I am (caned underprovslors at Chapter 9 SEWER F4AP r
(commencing with Section 7000)of Division 3 of the Business andsiZE NO OF STORES NO OF FAMILIES NEW - BI( Po }
Professions Code end Try license s in full force and effect d
License Number Lc ClaSs �� ADD ❑ VALIIATtON O
Contracts Date _ ALTER ❑ $ O V
Cr
❑ I am exempt under Sec REPAIR $
BEPC for the reason DEMOL ❑ Lo1AA P/C• I W
Date USE OF EXISTING BLDG URM ❑ G-
Cl)
Signature APPLICANT(PRINT) TEL NO LDA Perm• lqj, Q
Z
❑ 1 as owner of the property Or my employees with wages as =
their sole compereatcn wail do the work and the structure is ADDRESS CO _^'
not intended or offered for sale (SedxnT 7044 Business and
FINAL DATE F¢ 1 O I nl 105 -30
Prdesmons Code) lvLL THE AFpJGM OR FuruRE BJiLD AT OCLg11NT HANDLE A HAZARJ(%,lR MATE L %-23 �/ 10C.30 C
Elm r19 I as owner of the property aexC O9ively contracts with OR A MXTUiE CONPa A HAZA{7IX,N1a MATERAL EQUAL TO OR GREATER THAN TE Q ��Y, 111 .Jrl
AAcuNTs snEcsEo a+TTE HAZAAroous wTvara-v rsaramTpN Duos+ FINAL By >
lcersed contractors to construct the project (Section 7044 vEs❑ ra❑ irljr
(,}'Qt{ _ ,Illi
Business and Professions Code)
N1LL THE NTENAIEa OaE OF THE BUDLPq BY THE APPLGVfT OR RfTLRE BUILDING IF,
OCCU RE01AfE A PERW FOR CCNSTRampN OR A1O0R'GRpN FRi TIE a
CONSTRUCTION LENDING AGENCY � sD"''A'Tv A4NAOEMENn DISTRICT IsuDMOI BEE PEw.eTTNG clECKUST FOR 0000-000 1 vSI1 5I94
I hereby affirm that there a a construction lending agency for TEs❑ Mp❑ 651 1 All 4:.v
N the performance of the work for which the permit s issued(Sec uwE READ TIE 1uwlDas NATERwswowAATpNaApE ANn THE ncA,oIAO PEPon1irNO
m 3097 Civ C) , C]ECJOffiT 1 p1DERSOAD W MQUIR AEH19 vnER THE NRS A IES COIAnTY CODE
TmE a OHAPTER 2 p 3ECTICN9]711100 TiKxl(W Z Tp tA0 CONCERHNO HAZAlA0119
Lender a Name IMIEFL/La RENmnND ANO FOH OBO➢!WO A f£RMT FROM TIE BCAOAO ,
Lenders Address
0 oucn w Aaur
o I certify that I have mad the application and state under penalty _ r
of perjury that the above mformotan a coned I agree to comply PC FEE PERNUT FEE �O I
R with all county ordlrancae and State Lam relating to building
construction and here/ebyy byaaauuthonze representatives of the County, ISSl1FNCE FEE
ellt� -
^.1 t0 U`tslLr-' OQ�M11PaCDpn e9
m _�IA�IIVG/AGI 4 NVESTpATION FEE TOTAL FEE D , ff %1
Im
SEE REVERSE FOR EXPLANATORY LANGUAGE