HomeMy Public PortalAbout4947TEMPLE CITY BLVD_Building (2) LJ
W.9RKERS COMPENSATION DECLARATION
,� affirm that I have a certificate of consent to ,elf APPLICATION FOR BUILDING PERMIT
Insure or o certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lob C ) i -
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poh No cr F. pang
Certified C Is ereby furnished FOR APPLICANT TO FILL IN
/4 RIV ss
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tion
copy is filed with the county building mspec BUILDING i
non department /^7 T�/�) �,�/ ADDRESS
1A 17T5>1 y
Date Vail/g'Apphcont 5 L� JW4 � C,o/L/t>,7 CITU ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' - NOO OF BLDGS NEAREST A _
COMPENSATION INSURANCE SIZE OF LOT S- W ON LOT ST r,,
(Thu section need not be completed d the permit a for one ASSESSOR
hundred dollars($100)w less ) TRACE BLOCK l07 NO MAP BOOK PAGE PARCEL
TEL 115E ONE MAP
1 certify that in the performance of the work for which this OWNER 21L/' nIO D Y NO
KA
permit is Issued, I sha�ll not employ any person in any manner - SPECIAL T>_,
so as to become ss�uyy�sLb�yLeej/c,/t�/('o the Workers Ca-m/pensotlon Laws ADDRESS -a-// _ I- CONDITIONS 8
Date_,y[O Applicant 4il.L.. CITY ZIP �,Ea TY
NOTICE T APPLICANT If, after making this Certdicwe of ARCHITECT OR TEL DISTRICT UP TYPE FIRE PROCESSED BY
Exemption you should become subject to the Workers ENGINEER NO CONST ZONE
Compensation provisions of the Labor Code you must forth- ADDRESS 5-10 R• u LU
with comply with such provisions or this permit shall be L TATISTICAL, IF TION APT C N
deemed revoked O0NTRACTOR J_ORW fd Q Z
reLICENSED CONTRACTORS DECLARATION gnI LK CLASS NO ✓� DWELL UNITS_ r-
I hereby offum that I am licensed under provisions of Chapter 9 ADDRESS m NO SEWER
(commencing with Section 7000)of Division 3 of the Business and LK
Professions Code and my license is in full force and effect CITY CLASS 3 VALIDATION4
SO FT -NO OF NO OF CHECK BK PG
License Number LIc Class SIZE STORIES FAMILIES ONE
' VALUATION
Z
NEW
.0�� DESCRIPTION OF WORK s ,
Contractor S T J il l HV S to 6 O /
❑ I am exempt under Sec AM
ALTER - ;20769A,'
B 8P C for this reason REPAIR f # • • • (jy0TS}R•( �1
Date - USE OF TEL DEMOL NOH&
O 9
EXISTING BLDG
Signature APPLPRIM �L/I LLi m NO 0 - FINAL
OWNER-BUILDER DECLA TI N DATi
1 hereby affirm that I am exempt from the ntroctw s License # • • • • •I�
Law for the following reason (Section 7 15, Buslnass and ADDRESS - Fl
Professions Code) , I •r• 6 0,5 0
❑ BUILDING b a 5 0
I as owner of the property or my employees with ADDRESS • • .
wages ct thea sole intended
or on will f o the work and
the structure is not Prefiled or offered for sale(Section LOCALITY 0926-88
7044, Busse
nss and Professions Code) MOVING TEL
❑ I, as owner of the property, am exclusively contracting CONTRACrOR NO
with licensed contractors to construct the project (Sec- ADDRESS
tion 7040 Business and Professions Code)
CONSTRUCTION LENDING AGENCY REQUIRED SET BACK YARD HWY TOTAL PROP LINE WIDTH -
hereby affirm that there is a construction lending agency for FR- T
the performance of the work for which this permit is issued P L
(Sec 3097, Civ C ) SIDE
PL
Lender s Nome
8 , LDM\Ref 0 '
Lender s Address P C Fee S Permit F" 0-11 466 , J
I certify that I have read this application and state that the Issuance For •5 tDNA,P/C 0
above Information is correct I agree to comply with all County Investigation Fee I T•
ordinances and State jaws relating to building construction, sz)
and hereby authorize rojxesentoaves of this County to enter Total Fee TDMA Pam •
upon the above- /p0�
( ntioned prop Inspect) p� _/ _
LW nVBfe f0!WLANATORY LANWAOe
- Signature of Applicant or^gen Date , r