HomeMy Public PortalAbout5039TEMPLE CITY BLVD_Building (2) WORKERS'COMPENSATION DECLARATION C _ ! f^ _I; -,_ _s „,,: ">1 A+
I
insure
a cm that I have o ceriCome ns,ti n Int to self APPLICATION FOR BUILDING PERMIT -- - +
„insure ore icopy the of Workers Compensation Insurance L-11
or a certified copy thereof(Sec 3800, Lab C J - - (
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company - - -
❑ Certified copy is hereby furnished t ? +.` FOR APPLICANT TO FILL IN BUILDING 5^03 -
❑ - _ _ ADDRESS
Ceitified copy is fled wrth lw
the county ddmg inspec BUILDING
tion'deporrment 1 ` r ADDRESSI f t +
Date Applicant+ + CITY - — ZIP LOCALITY - - -
`CERTIFICATE OF EXEMPTION FROM WORKERS' t -
SIZE OF- - - NO-OF BLDGS - -- -- P&AREST-
COMPENSATION INSURANCE LOT NOW ON LOT ST
(This section need not be completed if the permit is for one - - -- - - - --- - - - - ASSESSOR,,. �„ - •-� - - -
hundred dollars($100)or,less ) TRACT BLOCK LOT NO MAP BOOK + ' PAGE PARCEL
USEZONEZONE ^ Z
I certify that in the performance of the work for which this OWNER - - NO NO
permit is issued, I shall,not employ any Peron in any manner / SPECIAL • - - --- - - -- - ¢¢
so as to become subject tc the Worker Compensation Lows A'ODRE55 CONDITIONS Q
iit 'V
Dot4!-1746 Apphcci Cm ZIP
NOTICE TO APPLICANT If after making this Cemficcte of ARCHITECT OR TEL DISTRICT _GROUP- TYPE_ _ - , FIRE BY C)
Exemption, you 'should become subject to the Workers' ENGINEER NO CONST ZONE rj
Compensation provisions of the Labor Code, you must forth- ADDRESS �IQ -314
- _ 6
with,comply_with such provisions or this permit shell be
deemed revoked, TEL I STATISTICAL CLASSIFICATION APT CON
' CONTRACTOR NO _ ' , _
LICENSED CONTRACTORS DECLARATION •+ - - - - - --I CLASS NODWELL UNITS_ - -
I hereby offam that I am licemed under provisions of Chapter 9 ADDRESS Np! " IIIIIIIIIIIIIIIIEW
(commennrg with Section 7000)of Division 3 of the Business and •_ _ . " .. -LIC --- SEVER MAP
Professans Code,"and my license is in full force and effect CITY LASS -' - "" VALIDATION
SO FT _ NO OF _ NO OF _ CHECK47
-
Licens. Number Lc Class SIZE STORIES FAMILIES ONE e
' • VALUATION
Contractor ° • , ` DESCRIPTION OF WORK - low
Date $
ADD
❑ I am exempt under Sec - j - -
,_ ALTER `.
B 8P C for this reason O W 1 K REPAIR
Dote - ' USE DEMOL
EXISTING BLDG S - - - -
signature _ _ APPLICANT TEL RNAL _
OWNER-BUILDER DECLARATION PRINT NO _ ___ ._ DATE z-�� .�J L� _ C _ _
-I hereby affirm that I am exempt from the Contractor's License i
Law for the followag reason (Section 7031 5, Business and ADDRESS r- FINAL/
Professions Code) - -' ,) By - - _
BUILDING
I as owner of the property or my employees with _ ( BUILDIss
wages as then sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOVdRV '
- `704/ Business and Professions Coda) _ MOVING- __ --' '- TEL - -"- - • I
❑ I, as owner of the property am exclusively contracting CONTRACTOR NO 1 :15 4 7 1 A
with licensed contractors to construct the project (Sec- '- • ADDRESS
tion 7044 Business and Professions Code) # • • • • • 1
_- CONSTRUCTION LENDING AGENCY REGUEDSET BACK YARD' HWY SETBACK
LINE WIDTH � I e,•,5 9 2 5�
1 hereby affirm that there is a construction lending agency for FROM
the performance of the work for which this permit is issued P - - - - - - - ' e e - 59 255
(Sec 3097 Civ C ) SIDE
PL '
Lender's Name _ _ _ _ _ _ _ _. _ _ _ _ _ O 9, 1 9 8 b
LDMA Ref M
Lander sAddress - -" - P C Fee$' - Permit Fee- J i -
I certify that I have read this application and were that the _ Issuance Fee �' -� t LDMA P/C 0 - --- -F ---
above information is correct I a to comply with all Ccun '
9r� l Y ty Investigation Fee
ordinances and State laws relating to budding construction Total Fee r IDMA Perm
and reby authorize representatives of this County to enter
n he ab elm ion d property for inspection purposes
SQ RNERB!FOR EXPLANATORY LANGUAGE I
Sgrature of Applicant or Agent Data - - --- -- - - - - - O'