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Home My Public Portal About4830TEMPLE CITY BLVD_Building (2) WORKERS COMPENSATION DECLARATION • . ^ hereby offum that I have a certificate of consent to self , APPLICATION- FOR BUILDING PERMIT DISI insure, or a certificate of Works"' Compensation Insurance, - i or o certified copy thereof(Sec 3806, Lab C) _ COUNTY OF LOS ANGELES - BUILDING AND SAFETY Policy No ' Company r BUILDING Certified copy is hereby furnished FOR APPLICANT TO FILL IN - ❑ ADDRESS 00, Certified copy m fled with the county building Inapeo- gUIIpINO T ^ Q/t'd non department ADDRESS 30 1 E.C4 \i p 17Lpvc( LOCALITY Date CITU to Ct• ZIP CRROOSSSSSt ZIA Date-Applicant CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT S6 K 75 ON_NCI OF 1U3GS f ASSESSOR PAGE vARCEL COMPENSATION INSURANCE LOT (This section need not be completed if the permit is for one TRAC714 46-7 BLOCK LOT NO USE ZONE NO hundred dollars($100)or less ) I certify that in the performance of the work fat which itis OWNER PtCULA. r_ I/r=UZ9SCu TE` 2A-2c37 7 CONDITIONS d permit Is Issued 1 shall not employ any person in any manner [�� p a _ DISTRICT GROUP TYPE FIRE PROCESSED BY O so as toCbecome isubject to the Wo�r�{k//¢a mpensat on Laws ADDRESS Tb 3 q / �-' is ii,ce n CONST U Bate zbe/e¢' Applicant - ��C- CITY 1 L/ - ZIP d ` /d �A7157ICAL TION - APT CONDO O , �TICE n, APPLICANT If, aNer making itis Certificate o1 EANRG�Is1E R - t�j TEL - C�NO�_DWEU. UNI15 W Exemption, you should become subject to the Workers d Compensation provisions of the Labor Code, you must forth ADDRESS - SEWER MAP - N with comply with such provisions or this permit shall be TEL Z deemed revoked CONTRACTOR NO _ BK PG \ VALIDATION LICENSED CONTRACTORS DECLARATION LIC t hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION ` (commencing with Section 7000)of Division 3 of the Business and LIC r Professions Code, and my license a in full force and effect CITY CLASS $ SO FT^ ? NO CIF- NO OF CHECK License Number Lia CI SIZE ` J STORIES e FJ�/AMILIES OPE Contractor joie DESCRIPTION OF WORRK(� Cr JX `O a NEW $ I am exempt under Sec �� T` '�^ �D0 ADD ALTER ❑ FINAL v B 8P C for this reason 0 DATE - REPAIR Dote EXISTING BLDG DEMOL FI / . - B Signature APPLICANT TEL PRINT NO OWNER-BUILDER DECLARATION ,q - - I hereby offlrm that I am exempt from the Contractor s License Law for the following reason (Section 7031 S, Business and RE - Professions Code) 1, as owner of the property, or my employees with BUILDING Tom' SO ( V O� _ ; - -. _ C_ 3 e 7 9 A wages as their sole compensation,will do the work and LOCALITY 2u•+ Ci the structure a not Intended or offered for sale(Section _ �{.. . . . . 7044 Business and Professions Code) MOVING TEL 1, as owner of the property,am exclusively contracting CONTRACTOR NO 2 - . 9 6 7 5 with licensed contractors to construct the project (Sec- tion 7044 Business and Professions Code) 'CESS • • . 96756 CONSTRUCTION LENDING AGENCY SEAT BACK YARD HWY TOT PRS CK INE FROM WIDTH ` I hereby affirm that there u a construction lending agent fat _ _ 108 -30-84 the Performance of the work for which this permit o issued P L � Sec 3097, Civ C ) yDE PL Lendees Name Lender's Address PC Fee$ Pmmn Fee O \ 1 certify that I have read this application and nate that the I�su"Fee above mformotlon is correct I ogree to comply with all County Inr.ahgo]Ion Fee - - ordinances and State jaws relating to building construction, Total Fee and hereby authorize representatives of this County to enter upon the ve-mentioned property for Inspecho purposes A0 S ^ �t/V L '•Ya C p130/I� fH RIVER$B FOR EXPLANATORY LAMOUA6l Signature of Applicant w Agent Dote 0a