HomeMy Public PortalAbout5011TEMPLE CITY BLVD_Building (2) i ,��t�--1'NORKERS COMPENSATION DECLARATION
.`I here, affirm that I have certificate of consent to self
orWorkers' - APPLICATION FOR BUILDING PERMIT
insure, a certificate of Co Compensation Insurance,
or a cegrfled copy thereof (Sec 3800, Lob C) COUNTY OF LOS ANGELES BUILDIN6 AND SAFETY
Policy No Company'
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
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❑ Certified copy Is filed with the county building Inspec- AMRE5�,5 J nI 1 w` CIL �E""
tion department ,`
,Dote Applicant - OTY CL OF jp U LCCALIrY
J NO CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
CSSES ST
COMPENSATION INSURANCE ASSESSOR
i (This AP section need not be completed if the permit is for one TRACT BLOCK LOT NO MBOOK PAGE PARCEL
hundred dollars ($100) or less ) NEtn{�.T TEL
' OWR I'`Zf V �o` NO 115E ZONE MAP.
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I certify that in the performonce of the work for which this SPECIAL
permit m issued I shall not employ any person In any manner ADDRESS C L ) V� — COND TIONS 0-
W
iso as t become subject to the W cert Compensation .. _ ._-
/� It'�� CITU ,L\� '4 �� ZIP I U Q,
J`�/'Date Applicant 'w ARCHITECT OR \ ,, , TEL C DISTRICF GROUP TYPE FIRE PROLE BV O
J , 'NOTI TO APPLICANT If ah making thi Cemhcat of ENGINEER W� s--fM(e NO l Z �/ CONST ZONE
Exemption, you should become subject t the Workers 3 ZS Q , _ 7. Q_
Compensation provisions of the Labor Code, you must forth- ADDRESS U W
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT I CONDO Z
deemed revoked CONTRACTOR NO ,�/� �
LICENSED CONTRACTORS DECLARATION UC PASS 1,104221 DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER qPG _
,
(commencing with Section 7000)of Division 3 of the Business LIC
and Professions Code,and my license Is in full force and effect CI NO OF 1dD OF CLASS CHKK BK VALIDATION ,
License Number Lit Class SIZE STORIES FAMILIES ONE
- - VALUATI
Contractor Dote DESCRIPPON OF WORK I ADD ❑ f
❑ am exempt under Sec - - _ n �� kfbC),i Ct 0 __ ALTER
B BP C for this reason 0.n Y-evNj del C tREPAIR $Date OF
XISTING BLDG D5NOL ❑
Signature APPLICANT _ TELFINALOWNER-BUILDER DECLARATION (PRINT) NO OAI hereby affirm that I am exempt from the Contractor a LicensegppRESbLaw for the following reason (Section 7031 5, Business and Prrfessions Code) ` I - By`BUILDING A(�as owner of the property or my employees with S R- �s �V k\ACCrT.*
wages as their sole compensation, will do the work and
LOCALITY { - �'�,- L ( { �� QMD7
4�.
the structure is not intended or offered far sole(Section
7044, Business and Professions Code ) MOVING, TEL
CONTRACTOR NO l 1 ITEttS
I as owner of the property, am exclusively contracting ' TAs
with licensed contractors to construct the project (Sec- ADDRESS '� ``l\\ N, �j 49. �
tion 7044 Business and Professions Code ) -.�Z t ` _� ,^ (,y�TAryL/ pppp
I YARD HWV ALSETBA FROM IST \ `\ J` '" -\`. l'\`�`W�M �9.GK7
CONSTRUCTION LENDING AGENCY .b s --,�
1 hereby affirm that there is a construction lending agency far FROM{ _` + j •�
the performance of the work for which this permit is issued P L . -
(Sec 3097, Civ C) SIDE
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Lender's Name - IDMA'Ref`N s1`,1 �1`- `}' `L uWV-WV1 7/iL07
PC Fee S Permit Fee ,, `,
Lender s Address t�s�� 1 AM 9.21
I certify that I have read this application and stcte that the Issaon e , IDMA P2 N
• above information is correct I agree to comply with all County
ordinances and State laws relating to budding construction, ioml Fee LIM4A Perm N.
` and her authonze representatives of a County to enter _ _ _ `_, , ,� \ . \'>= -,
gY) ypon he a ve-mention props (or epechon purposes//��QQ��rr \�, '
9E REVERSE FOR EXPLANATORY LANGUAGE
peal of Appl.:a Ape t f� �