HomeMy Public PortalAbout5039TEMPLE CITY BLVD_Building 1c y'WORKERS NOMPENSATION DECLARATION I
11 hereby d certificate
that I hf Workers
<eni omp of consent to .elf - APPLICATION -FOR BUILDING. PERMIT
+( insure, or a cenificote of Workers Comperaation Insurance `
(
or a certified copy thereof (Sec 31100, Lob C )- . - - -- BUILDING AND SAFETY
Policy No Company
WILDING � L�- e� if
❑ Certified copy is hereby furnished --FOR APPLICANT TO FILL IN - ADDRESS t !�b
❑ Certified copy is filed with the cou building inspec- BUILDING
� 3 (� �- � � I.�
hon department Ulb G=
Data Applicant CITY L �= Zme / LOCALITY
MWON LOT - NEAREST _
CERTIFICATE OF EXFJJRPTIO FROM WORKERS SIZE OF LOT - CROSS ST -
COMPENSATION RANCE ASSESSOR
• (This section need not be comp Is
if the permit is for ane - TRACT &OC( LOT NO —' MAP BOOK PAGE` — PARCEL
hundred dollars (E100)or less TEL USE ZONE MAP
OWNER NO
I certify that in the perform ce of the work for which this Z L�I, NOSPECIAL _
permit is issued, I Shall not a ploy any person in any manner ADDRESS �C et r' llJJ I CONDTIONS d
so as to bdco a subject to a Worl rs Compensation Laws ZO
6/ CITY G U Z' ZIP ��- ` U
Date App scant ` ARCHI OR TEL DISTRICT GROUP TYPE IRE PROCESSED BY Q
NOTICE O APPLICANT f, after making this Cemh of ENGINEER NO - CONST ZONE G
Exemption, you shout become subject to the Workers
Compensation prov sio s of the Labor Code, you must forth- ADDRESS y
with comply with su provisions or this permit shall be TEL STATISTICALCLASSIFICATION APT CONDO N
' deemed revoked - CONTRACTOR NO z
LICENSED ONTRACTORS DECLARATION DC CLASS NO DWELL UNITS_
I hereby affirm that am licensed under provisions of Chapter 9 ADDRESS NO -
(commencing with on 7000)of Division 3 of the Busmen LIC SEWER MAP '
and Professions ,and my license is in full force and effect CIN C1A55 BK PG I VALIDATION
SO FT NO OF rJ0 OF CHECK
License Number tic Class SIZE NO
FAMILIES ONE
• VALUATION
Contractor Dote DESCRIPTION OF WORK NEW ❑ _
❑I am ex mpt under Sec a 5TEADD ►
_ _ALTER ❑ - - `
B 8P for this reason REPAIR ❑ E _
Date USE OF .
EXISTING BLDG DEMOL ❑
S lure APPICANT FINAL -
OWNER-BUILDER DECLARATION PRltn
DATE
j her by affirm that j g r exempt from the Contractor's ss, and .. ,1 -)4117
L 4or this following reason (Section 7001 5, Business and ADDRESS VY' - RProfessions Code) NT _ - By
I as owner of the o BUILDINGpr petty, or my employees wnd g00jRES5 wagesas then sole ntendecompensation,ff rwilled do rhe work tion ,lhestructure isnot intended or offered for sale(Section LOCALITY 70M, Business and Professions Code ) MOVING JEL
CONTRACTOR NO I,as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- g00RE5G •�tion 7044 Busmess and Professions Code )CONSTRUCTION LENDING AGENCY YARD F/Urs' TOTAL SETBACKPROP EFROM, ISTI hereby affirm that there is a construction lending agency for FRONTthe performance of the work for which this permit is issued P L9.�i(Sec 3047, Civ C ) SIDE h+PIL .87
Lender's NameMA Ref PC FeeSLender's Address
I certify that 1 have read this application and state that the Is+ rc o LO &A P/Cabove information is correct tocomply with all County Invesliootion Fee ( 1 8:48
ordinances an r -building construction, I Tota WMA Perm 0
and here a t of this County to enter _
u n perry for
inspection purposes
- B �,
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SIR 8
MWM AGE
Sign re of Apphmnt r Agent Duro ...