HomeMy Public PortalAbout4918TEMPLE CITY BLVD_Building (2) •RKERS COMPENSATION DECLARATION is
hdr1eby affirm that I,haver certificate of cement to self APPLICATION FOR BUILDING PERMIT
insure or o certificate of Workers Compensation Insurance, '
Or a certified copy thereof (Sec 3800, Lab C ) _ . - COUNTY OF LOS ANGELES - BUILDING AND SAFETY '
-Policy No Company p
`i❑ _Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADSS 9/O
El Certified copy Is filed with the county building Inspec- BUILDING s - '
tlon,depariment - '�
Date Applicant CITY r ZIPQ912ko LOCALITY -
IV
_ - NO OF BL NEAREST
CERTIFICATE OF D(EMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST
COMPENSATION INSURANCE ASSESSOR_
(This section need not be completed if the permit is for one ' TRACT BLOCK I LOT NO MAP BOOK i PAGE I PARCEL
• hundred dollar ($100)or lea ) I - TEL
OWNER NO USE ZONE MAIN 0P / �'
I,certlfy that in the Performance of the work for which this Y
t permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL a
.so as to become subject to the Worker Compensation laws CONDITIONS+ OU
• _ • '_ CITY ZIP
Date Applicant ARCHITECT OR TELQc
DISTRIR GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT If, cher making this Certificate of ENGINEER - •NO - t CONST Z r
Exemption you should become subject to the Worker
Compensation provisions of the Labor Code, you must forth- ADDRESS - ��4 -J / !•G's-a4� �'�'
with comply with such provisions or this Permit shall be TEL STATISTICAL CLASSIFICATION _ APT_ CONDO Z
deemed revoked I - I CONTRACTOR NO —
LICENSED CONTRACTORS DECLARATION UC CLASS NO a DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO
(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP
and Professions Code,and my license is in full force and effect CITY NO CLASS BK PG VALIDATION
SQ FTCHECK
License Number Uc Class SIZE STORIES FAMIUFS ONE
„ NEW El VALUATION
Contractor Date— DESCRIPTION OF WORK s PDO LJS ���a '
❑1 am'exempt under Sec pop1:1ALTER pp1I
B 8P C for this reason REPAIR pJ $
Date USE OF L
EXISTING BLDG DEMOL ❑ _
Signature APPLICANT _ TEL, FWAL i rP_11 .7 '
OWNER-BUILDER DECLARATION (PRINT) NO
I hereby affirm that I am exempt from the Contractor's License - - • - - - - _
Low for the following reason (Section 7031 5'Business and ADDRESS FINAL I I EITZ
t
Professions Code) - IN - _ _ ,_ By TIJI A, 98 ® 63
I as owner of the property or m employees with BUILDING _
P PertY YADDRESS T
wages ct their sole compensation,will o the work and LOCALITY
the structure n not intended or offeredf for sole(Section
704, Business and Profeaiom Code ) MOVING - • - TEL - • - - ,,
❑ 1, 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 - _- - - CCI_0-1_•1I i i
CONSTRUCTION LENDING AGENCYSET I YARD HWY OTAL IINEfRQM WI
EXI
I hereby affirm that there is a construction lending agency for FRONTthe Performance 30of the work for which this permit is issued PL_
(Sec 97, Civ C ) SIDE
PL
lender s No" - -
LDMA Ref I - r
„OA� ��
PC Fee S Permit Fee J a
Lenders Andrea�E•/ ((/4Pj _ _ �/'/
1 certify that I have read thisapplication and state that the _v. Issuance Fee oc 7 S LDA1A P/C I
above information Is correct I agree to comply with all County Inreahgohon Fee - e
ordinances and State Iowa relating to building conatruchon Toal fee 1DMA Perm N
and hereby authorize representatives of this County to enter _ _ _
upon the abov ntione roperty for mspectlo purposes +
fEE RMW FOR R%PLANATgLY LANGUArN
Siq are of Ap mant or Agent Date