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HomeMy Public PortalAbout5020TEMPLE CITY BLVD_Building (2) WORKERS COMPENSATION DECLARATION . e6y affirm that I hove a certificate of consent to .elf APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compensation Insurance or a certified copy thereof (Sec 3800 Lab C ) rr Policy No6q'/ 0 V88 Company S'rRT� rvyC/ - COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING n U ���///--- ADDRESS �Cen department copy a filed with the county building inapec BUILDING d�� �/'/7 f bon department � AWItE55 /f r Date 12 - �-Sf Applicant `v t 'v` r CITY C ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS DEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT ST - S ') (This section need not be completed of the permit is for one _ - hundred dollars ($100)or less ) TRACE BLOCK LOT NO MAP BOOK PAGE PARCEL I certify that in the performance of the work for which this OWNER O ss NMAP O �g6 ^y� /7 JANE NO permit is Issued 1 shall not employ any person in any manner ADdif55v u K I SPECIAL S p so as to become subject to the Workers Compewws U motn La Date Applicant CITY ZIP NOTICE TO APPLICANT If after making this Centficate of ARCHITECT OR TEL 0 ENGINEER tp DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption you should become subject to the Workers r\ ��T� Z U Compensation provisions of the Labor Code, you must forth ADD s (f ' L8J. with comply with such provisions or this permit shall be " L 1 STATISTICAL CLASSIFICATION APT fn deemed revoked CONTRACTOR Wl/L NO Z LICENSED CONTRACTORS DECLARATION + n/� /L 0 LIC OASS NO - DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS T 1 6 A 61.1 NO/L SEWER (commencing with Section 7000)of Division 3 of the Business and LIC Professiom Code and my license is in full force and effect CITY 1 M t CLASS " 1 BK VALIDATION SO FT NO OF , NO OF / CHECK Licen»Number Lic Claal SIZE STORIES FAMILIES ONE vALuwnoN - contract s /( I; DESCRIPTION OF WORK O?Lo- NEW $ ySOQ d0 I am exempt under Sec u' �a G6' ,<Y ,tet 4 But Ld ADD S pool - - _ //yu�., ��•• /. ALTER l B 6P C for this reason I F1/1 v14 Tat !� OD !� fJ0 REPAIR Dote USE OF EXISTING BLDG MINtrNI Signature '°'PPL� T - TEL FINAL �Z /�f,7 126.4 A OWNER BUILDER DECLARATION JpATE ` !J • 1 hereby affirm that I am exempt from the Contractor Is License # •'s s • •)J' Law for the following reason (Section 7031 S Business and ADDRESS q Professions Code) 1T U60F '1 • • 7 a O O I, os ownerof the y p y BUILDING 7 a O O i property, or m demployees with ADDRESS s s s p wagescis their sole comped a Orlowill the work and LOCALITY the structure Is not Intended or offered for ered for tale(Section ;1 202-88 7044, Business and Professions Code) - MOVING � � - 1, as owner of the property, am exclusively contracting ' with licensed contracton to construct the project (Sec ADDRESS tion 70", Business and Professions Code) CONSTRUCTION LENDING AGENCY gnu YARD I HWY U IDTH 's I hereby off um that there is a construction lending agency for the performance of the work for which this permit Is Issued P (Sec 3097, Civ C ) SIDE PL Lender's Name 8LDMA Ref / Lender's Address P C Fee i Permit Fee . tI certify that I have read this application and state that the Issuance Fes lo � v ,IDMA P/C/ above information is correct I ogres to comply with all County Invest ion Fee $ ordinances and State jaws relating to building construction, Total Fee f IDA1A Perm'1_ L., R and hereby authorize representatives of this County to anterIIIIIIII upon the obovve.mme�ntion�ed Fir /yf�J�Y far inspection purposes fO tfVBfi 101 EXPLANATORY LANWA61 Signature of Applicant or Agent_f Dote _