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 _