HomeMy Public PortalAbout5002TEMPLE CITY BLVD_Building s WORKERS COMPENSATION DECLARATION
sal hereby affirm that I havecertificate of consent to ,elf APPLICATION FOR BUI�DING PERMIT
insure, or a certificate of Workers
Com
kers Compenaat.on Insurance, ,
or a certified copy thereof (Sec 3800, Lab C ) iOGUNI OF LOS ANGELES �j •�• 46UILDING AND SAFETY
Policy No Company ,
Certified copy is hereby furnished_ FOR APPLICANT TO FILL IN ADDRESS
EJ GQ�'
ElCertifiedcopy Is filed with the county budding Inspec- BUILDING
hon department r , -
bate Applicant CITY ZIP — LOCALITY
�7 NO OF NFARLST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT hoc ! NOW ON LOT ?� CROSS ST
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one TRACT - BLOCK I LOT NO - ASSESSOR
MAP BOOK PAGE �' PARCEL
hundred dollars ($I OD)or less ) TEL USE ZONE
I certify that .n the performance f the k for ch this
NO
permit.s issued, shall not emploYou ny any anner ADDRESS Y - ' COON'NOND TIONS - a
w as to become subject to the IJ. n Laws O
���j�}a�./a/� CITY _ ZIP_ U
Date s2__y&` �Apphca ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT If, ak ng thn Cerl.f.cate of ENGINEER NO CONST ZONE O
Exemptici you should become subject to the Workers .'{ G
mns
Compensation prov.sof the Labor Code, you must forth- ADDRESS �7� D� '✓ � 1t
with comply with such provisions or this permit shall be TEL STATISTICAL FICATI CONDO N
deemed revoked CONTRACTORNO ?
LICENSED CONTRACTORS DECLARATION UC CLASS NO D i as—
I hereby affum that I am licensed under provisions of Chapter 9 ADDRESS - NO SEWER MAP
(commencing with Section 7000)of Division 3 of the Business UC c
and Professiom Code,and my license n.n full force effect 5Irye NO CLASS CHECK BK lr 2 l 23 VALIDATION
�J / J
License Number:/ L�G.7[.;MV_ L.c�Clau SIZE �O STORIES FAAVU6 ONE a
NEW
f Z D Z DESCRIPTION OF WORK EliALUAn, �/'� Ib 307
ACCTA
Contractor—Y Date 6 ill•_ ] 43,75
I am exempt under Sec ADD 1:1El _ ALTER LJ pool 3W7 325.43
B&P C for this reason REPAIR ❑ :
Date I&I D—`iL oEa�oL ❑ 2 ITE175
IX TIING BUX3 TOTAL 374 . 18
Signature APPLICANT
_ - _ TEL FINAL -
ER-BUILDER DECLARATION (PRINT) NO DATE ,"Z. CASH 324.1�
I hereby affirm that I am exempt from the Contractor's License _ _ _- _ _ DATE ,aa
Law for the following reason (Section 7031 5, Business and ADDRESS
MEE
Professions Code) PRESENT - _ �y _
❑ I, as owner of the property, or my employees with BUAD� \ - _ T
wages os thetr sole compensation,will do the work and 1 - = - - - \��a 1 12/_11/K
the structure is not intended or offered for sale(Section LOCALITY , - - , '1 , ;�r (` 7012 1 AM 9.137
)
7044, Business and Professions Code MOVING
r
El 1, as owner of the properly, am exclusively contracting CONTRACTOR NO
with licensed contractor to construct the project (Sec- ADDRESS n _
tion 7044, Business and Professmm Code )
CONSTRUCTION LENDING AGENCY 11 YARD , OTAL EPROM T f-C. r• `i `
I hereby affum that there.s a construction larding agency for FRONT
the performance of the work for which thea permit is issued P L. - -
(Sec 3097, Civ C ) - SIDE
PL
Lender's Name
IDM4 Ref Y
PC Fee 7 Perms Fee D'
Lenders Address - -
I certify that I have read this application and state that the Issuance LDMA P/C Y
Poo
above information.s correct I agree to comply with all County Invesugm.on Fee 3 -
ordinances and State Iowa relating to building construction, Total Fee a:/,�T D.Perm Y
Q and hereby authorize representatives of this County to enter
RY$ upon the above-mentioned property for Inspection purposes
WE YEVEM KM FIVLANATORY LANGUAGE
Signature of Applicant or Agent Data