HomeMy Public PortalAbout5038TEMPLE CITY BLVD_Building • — APPLICATION FOR BUILDING PERMIT c,,
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKEWS COMPENSATION DECLARATION FOR APPUCAPfr TO FILL IN X01
I hereby affiml that I have a cartlncats of consent to sen Insure au ADORERS . J
or•cartl11ca0s of 1Atorkers'Compersabon Insurance,or a certified
Dopy thereof(Sec 3800.LaD Cyy)) LP
Policy No li CompanyLOCALRY
OF ICT 110 of au)(iS NOW ON LOT
❑ Certified ODp I shed NEAREST CROSS
ST
M-CwI copy Is filed with the county budding Inspection TRACT at= LOT NO (Z L =I S !
department
��IL
�,, y]`�/ USE ZONE MAP No
f=LlL-=L/¢purer ASSESSOR YAP BOOK - PAGE PARCEL - SFrC1AL ONS
CERTIFICATE OF EXEMPTION FROM WORKERS' O YES NO
COMPENSATION INSURANCE WITHN 1000 FT OF SOIDOLT
(This section need not be Completed If the pennd is for Urea hundred DISTRICT (ROUP CONST FmEZONE PROCESSEDBY
dolma(1100)or lase) - Z
I cwey that In the performance of the work for which the permit
is iswud. I dell not empty any person In sly manner w®ro ITECT OR ENGINEER TEL NO
become subject to the Wlorkers Compensation LBM STATISTICAL CLLAcWICATION APT CONDO
Dete Applicam ADDRESS CLAW NO DWELL UNITS
NOTICE TO APPLICANT if attar making this Certdlcate of �S�nTRF�T REOUSiED TOTAL SETBACK FROM n
Exemption you should become subject to the Workers' TEL'NO BACK YARD HWY PROP LtNE
ComPemetlon WovWons of the Labor Code you must forthwith
comply with such provisions or rho permit shell be deemed revoked O� 1 LIC NO FRONT Y
PL
LICENSED CONTRACTORS DECLARATION uc _ v of 8
1 hereby aMrm that I am licensed under provisions of Chapter,g SEWER MAP
(COMMOncirlg with Section 7000)of Dhnwon 3 of the BUalnese and SO FT SIZE NO OF STORES OF FAMIuE NEW ❑ BK PB ix
Professions Code and my license is In full force end effect F-
License Numbw LIC Clave C OF ADD ❑ VALUATION w
Cantraol���,Aee�� 7 O�S ALTER ❑ E _
❑ I am exempt under Sac REPAIR ❑
B BPC for this reawn DEMOL ❑
LISE OF EXGTMG BLDURM G LDMA PICS
bets
�— .-s ❑ j
SiU ��5��"`i� /�� (PR1NT1 LZEL NO LOW Penn s
❑ 1 as owner of the property, cr my employees with wages w ✓s7' 1 G G ZQ _`
their sole campmmetlan,wit do the work and the atncums Is AoDS�s F -.I_�
not Intended or offered for sale (Section 7011 Business and LA'�'��""'w' / RNA
LDAn y� _ < a
Profenorts Lode) waLTIaIAPPl1LMnTOI1M1➢LLNAJIaM100LlI1MNrIWImIIAIMLJ�OIMMAT9WL -/✓-9� A I� '}•
❑ 1 tl owner Of fileDop am etduey ong Wea
licensed contractors to construct the project (Secdbn aTI(l EAAYIoOxlrwlArae ecPaENCIurE.DmOnN ATHNEANzAwZoAAaDOrsUM6 eNAvTvuralA1pe,l,l,f.O.nRYl AoRaCNoAaeeAoTen+TNAN FIMAL > I Tx.�1.r1r.
70N, - /
BBe+neee and Professions code) "®❑ "° TOTAL 216 - 30
disc TE artomw use ter TK eransnD w Ili APR1CAMr On anus araDv10
OCQMNr IaDlxqArena.Foamrarwronarraa r.onnra„orAro.r Tl�solmr I_HEi't
CONSTRUCTION LENDING AGENCY 'TM1°' 1O1pI BM PeOiR"o a'FOR
1 hereby afftrm that there is a comtrumon lwlding agency for van❑ CHANGE
rhe? Ch,performance of the Work for which this Permit b Rued(See 3D97 rove BEAD TE NAzamam MareruAu seOrOL nON romena AND necAalm x /V �-/SST
90W CHC) rvssrnNo acanrsr I ulwesrAln Nr r<ouseorn uxoln ra Los ANODde
couNrrcoee,Tmez anPrzsersaemrarsrs 1m Ral0UI111S8L11�100MCeMq
Lande's Name rys�lgpyvpwn uoFDa ArEnrr mcune xwao I eoc-I'L1�1{ 11110/cr
I.elldelt Address ,err •�••••.__ J J V J 1 A'1 J i7.i
I Tartly that I have read this application and atste that the above
with all county
OIdnarces andrntatIon Sta�laws rd tling W building construction acrid PD FEE � �/ PERMIT FEE '
hereby authorize rspresenteuvss of this Courtly to enter upon J ISSUANCE FEE Y
®- 7 DIyN WTION FEE TOTAL FEE
of
SEE REVERBC FOR EXPLANATORY LANGlll1G!