HomeMy Public PortalAbout5002TEMPLE CITY BLVD_Building (2) APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATIONeu G A E FOR APPLICANT TO FILL IN BU.DING RES C,y� L[ / ,BL✓b.
I hereby affirm that I have a certificate of consent to self Insure O / �`I
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« a certificate of Workers Compensation Insurance « a certified �, 917 f-10
copy thereof(Sec 3000 Lab C) L /1 / '7 �/7
l� l u - LOCALRV
Policy No Company SIZE OF LOT NO OF RI DGS NOW ON LOT
❑ Certified COPY Is hereby furnished I NEAREST CROSS ST
❑ Certfod Copy a filed with the county building inspection TRACT BLOCK LOT NO
department I I USE ZONE ~NO
Dale Applicant ASSESSOR MAP BOO( PAGE PARCEL
sPEcul coNanoNs
CERTIFICATE OF EXEMPTION FROM WORKERS �I Sl. 3 x_91 1 I
COMPENSATION INSURANCE v�vSS WITHIN 1000 FT OF SCHOOL? �5 r'1O
(This 6eCtpn need not be completed d the panrml a l«one hundred QRZ^O O� A' I EM4' C /�L/bDISTRICT GROUP T`(yy CONST FIRE ZONE PROCESSED By
dollars(E 100)or keit) J /{"�s��_
I car that m thB performance of the work I« which this pemul 1� ? p 1
m Issued I shall not employ any person I ner so as to Y ��PLS y/- zIP E O ^ ,O I - ...J
tpec the Workere p EWS ARCHITECT OR ENGINEER TEL NO �[/
STATISTICAL CLASSIFICATION APi CONDO
Date'/ Apps ADDRESS CLASS ND DWELL
IlIIRS
NOTICE TO APPLKJ1NT IIter mekrng this Certifoete OT REQUIRED TOTAL SETBACK FROM EXIST
Exemptpn you Should become subject to the Workers ///�/) S,7- �T)E(I/A`�DJ,/�7 SET BACK YARD HWV PROP UNE WIDTH
Conpensatlon pruwsons of the Labor Code you must forthwith 2 •/ !'z 4 f Y `'`� / / FROM
comply with such provisions or this permit shall to deemed revoked
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LICENSED CONTRACTORS DECLARATION C
G� / LIG S P L
I hereby affirm that I am licensed underprovlsarre of Chapter 8 SEWER MAP }
(Comer ting with Sectipn 7000)of DNsuon 3 of the Business and SO FT SIZE NO OF STORE NO OF FAMILIES d
Professans Code aril IDense is m full face and effect NEW ❑ BK PG U
7 3 /3 DESCRIPTION OF WORK WLUNTON _ ,
license Number�L Luc Class � ` ADD ❑
CanVacl«�.� G.2iF✓�j Date /�•/ -93 —led
d10 S ALTER ❑ $ ��• eO W
❑ 1 am exep « ef
t dSec v RO
EPAIR ❑ $
m
BBPC f«this reason .5f9v0 o/�y f PL DEMOL ❑ �P/C I LU
USE OF EXISTING BLDG URM ❑ 1 N
Spnature n r =
APPLICANT(PRINT) TEL NO LORA Perm♦ ACCT.i
❑ I m owner property « my employees wnh wages as = _
their sok peraaten will do the work and The structure a ADDRESS I!,�I T �µ ���.f:
notnterded ore //-ered f« sale (Section 7044 Business and FINAL DATE
PreksR«e CodG i ITEhfJ
wll nE APPLIChNi OR MLPE BULOWp OCUAVIT INN0.E x W.SIAO«IS IUUEW.. zZ-93
❑ I as owner of the property am exaluswely contracting with OR A MTxrIXE CONTN n HAZAIDOUS NAnE EOWL TO OR Gn TER THAN THE
IDBrLsed COnilaClOre 10 COnsh11CT the protect ($BCt10r1 7044 AMOUNTS SPEC D ON THE HAZMOOUB WTERN LIFO TION GLIDE' I7T I 1
FINAL BY > T_ f� lc3 4 _
Business and Proleaswns Code) YEs❑ No❑ �/ UE(Y, 17.4`
WILL THE NTENDED USE OF THE BUDLfK BY THE IPRCMT DR FlITURE BLRnIq
UTH
CONSTRUCTION LENDING AGENCY OCCURWR RE Y A FEwsr Foo CARICT l TON oR I,aoI RIAT N FRH.T�n FOIR
COAST AN CW1fTV MNYeEMENT DL4IRCT IELA«.ASI ME PERMIIiN6 CHECKuaT FOR J
OLDEUE9
I hereby affmm that there is a construction lending agency for Yes❑ Ho❑
the performance of the work f«which this permit it Issued(Sec
m IHi6'Er£M TIE IIAZARpO1prMTERVL4 ofORMATONOtAIE AD TIE 9LAOLD PERNTTND •) r� VJVV—V'JJ1 LU 1/�_
Lenc CN C) TITUE 2 ST ua 220 M L11'IEWIELEIf15 UDER n i4D ANGEIEs CCUMr CODE I l I [.�`� C
Lenders Name W P145 REPPOORIING wn FOUR OBTUN O AA PERIAn FR�OMI•TH uo � / ^,j7y 1 f'Mi2:l]9
Lenders Address
0 o+�R aR.aFNr
I Certify that I haae rapid this applicatlah and state under pennahy PC FEE PEfWlT FEE
8 d perjury that the above Information s correct I agree to cartpy A2 7,
O
$ with all county orCinanrekh
Des and State laws ng to bustling a�
to o the bmentwored props �f«in9pBCU011 purposes ISSUANCE FEE 4/ VP,
m o.0 f INVESTIGATION FEE TOTAL FEE , 3
SEE REVERSE FOR EXPLANATORY LANGUAGE