HomeMy Public PortalAbout4829TEMPLE CITY BLVD_Building (2) APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL W BUILDING ADDRESS
131 yet-
I hereby olltrnh ter
hat I here.ctlKlam of consent m eeH Insure But=
I.G C'a�'f
or a certificate of Workers'Compmissaw Insumnce,or a certifled �, P
copy thereof(Sae 3800,Labif-4-ty CA
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POWYNo.116Q���0O Companry 7� f � -Y LOCaury
tLZE OF LO NO OF BLD[i.9 NOW ON LOT
XCertlfled copy is hereby humbhetl NEAREST CROSS ST
❑ Car9ned copy b filed with the county bulklmp inspection n:7ES
BLOCK LOT NO tl9Ez `otJ�✓ A
departrinentT�� p ( 6 o
Deft U�App ficant. r +-�'r c PAGE _ corrorr,oNs
CERTIFICATE OF EXEMPTION FROM WORKERS' �'NO
9,0 COMPENSATION INSURANCE _ — WITHIN 1000 FT OF SCNaoLT YES NO
(Thbesction read not be completed If the pertnHbMoro hundred � DIafRIOT^ O�RWI^P FIRE ZOtlo1Wa(fToo)or lean) ZIP vo 'i. ) '�)
I owtify Uet In the performance of the work for which this permit
It issued, I shell not employ any person In arty manner so as,to ARCKFTECT OR ENGINEER TEL NO
become subject to the Workers Comimmiation Laws STATISTICAL CA710N ^ CONDO
DUs Applicant ADDRESS LIARS NO DWELL UNITS �f
NOTICE TO APPLICANT If after making this Certificate of REO ED TOTAL SETBACK FROM oosr
EKemptlon you should become subject to the Workers COHfAA CR TEL NO SETBACK vARD MM'I PROP LINE W'ID'TH
Compensation provisions of the Labor Cada you must mrttwKh W .ZLtG — O
comply with such provWoM or this pemet"I be Seemed rsroked AD PROM
PL
LICENSED CONTRACTORS DECLARATION 2 c_PI- 4 R O LIC CLABB� SIDE
Il
1 hereby affirm that I em licensed under pnovlslone of Chapter 9 PL
PL APAP
(commencing with Section 7000)of DNnsan 3 of the Business and 30"SIZE NO of 11DRES NO OP PAMWES Oc
Proleeelons Cods,and my license b in lull force and NEW BK PG pop.License Number Luc Clem DESCRIPTION OF WORK ADD VALUATION
canuaaorDam a ALTER ❑ •� 9'3/
❑ I rim,n>empl under Sec
REPAIR ❑ $ —
BBPC mr tics resson DEMOL ❑ LDAIA P/Cs
Data USE OF o usnNG BLDG URM ❑ _
r '
Signature APPLICANT(PRINT) TEL NO
LDAu Perms
❑ I as owner of the proper on my employees, with wages es
their sob compmsebon will do the work and the structure Is ADDRESS O
not Intended W offend for Sale (Section 7044, Business and 'FINAL DATE
Professions Code) Wl1TEAPPl1D 01%1 T 111J D OCOUPANrhwa]LeARATARDO"W ef81ML S�� 7-9/ - G7
❑ I sa owner of the property, em IOcWewe con OR A NIznA1E cvNTNcavo A IwAaooue saT[wAt IMCK1 To an anATer TMR i
y with 1HE ArrOl rrre mON Tie mu7AlNalls lMTDUAIa KOIYAThaR aaoer MAL ay-1
U >
Wansed and professions
o epode) t the protect (Section 7041 vas❑ No
Rumness and Profsaeiorme COM)
ua.L ra INreo®ueE oP ns Bnll]o1a er 1Ne APNlC.rM Oe nlrlsls euioaq /{
OOWfMNTIRaU1HAPOYRfgICOM81RU MQOWsea Galant naNTIlaaUTN S /1 N� 7]CfYAn>mo
CONSTRUCTION LENDING AGENCY ��Aoa�m-oa�wqul�r uwuaomn aslwa*Ieanvn eE£Peacrtlno as�cauer c/ L///1Ya�� �`''` ��
I hereby affirm that there Is e oo strucbon lending agency for my❑ ....RI .
the performance of the work for which this permit Is Issued(Sec S�(_
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908'7 CNC) Ireumvo urmaurn iwar
LsndWS Name TRlau: �eEmroAlSsai AAauar� ti
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Lender's Address
LNWVEsnaATK)N
1 oerbly that I have read thin application anti stats that the above P�YIf71fiEInformation Is correct I agree to compy with all county ortlksnces and Stam laws,retailing m bu8tling corstructlom andhereby suthanm reprewdetlrae of this County m enter upon ISSUANK I%above-mentioned proper for inspection purposes I,JPEE TOTAL I C .a.
BEE REVERSE FOR oIPLANA ESE '