HomeMy Public PortalAbout5025TEMPLE CITY BLVD_Building (2) V,PQKERS*tOMPENSATION DECLARATION L ^
insure
affumlrhat I have a cs Come of consent to self APPLICATION FOR BOILbING PERMIT DLII IIIS
insure or a certificate of Workers Compensation Int to self
- - _
or a certified copy thereof (Sec 3800, Lob C ) _ F
l,�gZLe t1,,.� ��, - COUNTY OF LOS ANGELES.__ _ BUILDING AND SAFETY -
Policy No /Z1_YZCompony �/�'/t /✓� �J
❑ Certified copy is hereby furnished PPLICANT TOnnFILL IN T BADDRESS
Certified copy Is filed with the county building trapec- ADDRESS
tion department J
Dae -Z 9' Z Appbmm �"�S ��ss �q a v 711 LE C zIP LOCALITY
' I NO OF BLDG5 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE 1 SIZE OF LOT NOW ON LOT CROSS Si F<0'.50—
'
'.50—
COMPENSATION INSURANCE •'J�
(This,section need not be completed d the permit is for one TRACT &Cs7( LOT NO ASSESSOR 8.590
hundred dollars ($100)or less ) - r ra MAP Boa S 0 pAGE O 15 PARCEL OI
OWNER WI(,L.J09M J7 NO USE ZONE MAP
•I certify that in the performance of the work for which this n NO
SPECIAL - }
permit is issued, I shall not employ any person in any manner ADDRESS $02- CONDITIONS G.
'W as to become subject to the Workers Compensation Lows O
' CITY C.- Z( V
Dote Applicant ARCHITECT TEL
NOTICE TO APPLICANT If, offer making this Certificate of ENGINEER NO DISTRICT GROUP C ffFLST �lO E PROCESSED BY O
Exemption, you should become subject to the Waken' V� _2 t/ 15
15
Compensation Provisions of the Lobar Code, you must forth- ADDRESS v :5 Y
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT COnDD
deemed revoked CONTRACTOR /LfJL/ A/sr NO -� -- Z
LICENSED CONTRACTORS DECLARATION.• ADDRESS LN 032 CLASS NO a DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 LIC SEWER MAP
(commencing with Section 7000)of,Dtvtsion 3 of the Business _
and ECK
'a11 ofetwors Code,
and my license is to full force and effect CITY U �-u BK PG VALIDATION
Lic,�enle"N,�`,- �'fW32' Lic Clan ZE IT o ES I FFAAMIOLIEES or
��f/ri7Lcx, vALUAnoN
TContractor_('/LA7S77LL7Cn DAl Dote /—�(<-9Z DESCRIPTION OF WO v +' NEW, ❑❑ -
❑I am exempt under Sec
ALTER ❑
B 8P C for this r n — Vt7JP-6D O REPAIR ❑ $ _
EXOF
EXISTING BLDG —I 91W 1 DEMOL ❑ - _=i.7
sgnotur 4zm ''' (PRL �1� (. ry. oc NO —oo30 FINAL
WNER-BUILDER ECLARATION / DATE L
I hereby affirm that I am exempt from the Contractor s License 7ClL OUST. 5
Low for the following reason (Section 7031 5, Business and ADDRESS FINAL I IJ I yL tti-3 '.x >. 479'
Professions Code) PRESENT __ _ NONE Y -
❑ 1, as owner of the property, or my employees withBUILDADNG
DRESS
T
wagescis their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code ) I MOVING TEL
❑ 1 os owner of the property, am exclusively contracting CONTRACTOR NO '
with licensed contractor to construct the project (Sec AGGRESS
non 7044, Business and Professions Code ) _ _
CONSTRUCTION LENDING AGENCY SREQUIR ET D YARD HWY OTAL SETB.4 N FROM I7 S-r127 _ j �"K I
I hereby affirm that there is a construction lending agency for FRONT E WIDTH
the performance of the work for which this permit is issued P L '
(Sec 3047 Civ C ) SIDE
PL
Lender's Name
- '� .r"i LDMA Ref Y
P C Fee Perm.t Fee 7
Lenders Address
a I certify Lha I have read this application and nate that the Iwuance Fee _0 LPDMA P/C 1
above info anon is torr. I agree to comply with all County Invesnganon Fee p
ordmo and to I ng to bnstruction,building coTotal Fee �O ' TDMA Perm 0
Q and r au nze at of ilio County to enter
pYq opo for inspection purposes
WE REVIRSE FOR EXPLANATORY LANGUAGE -
Slgnature of App scant ar Agent Dote