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HomeMy Public PortalAbout5114TEMPLE CITY BLVD_Building WORKERS COMPENSATION DECLARATION 7y '.I hereby affirm that I have a certificate of consent to "If APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers Compepenahoron Insurance or � a certified copy'thereof (Sec 3800, Lab C ) - COUNTY OF LOS ANGELES BUILDING AND SAFETY -Policy No Company BUILDING Ce tbed copy a hereby furnished FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec BUILDING / hon department ADDRESS LOCALITY Cw NEAREST ((LL Date Applicant CITU IP CROSS ST SET CERTIFICATE OF EXEMPTION FROM WORKERSNO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT- MAP BOOK PAGE PARCEL -i(This section need not be completed if the permit is for one - _ - - USE ZONE— MA T - -0) hundred dollars ($100)or less ) TRACT BLOCK LOT NO -p `� NO OL } OW NE TEL z/ CONDITIONS SPECIAL1 0 I cem(y that m the performance of the work for which this DISTRICT TYPE FIRE SSED O permit is Issued I shall not employ any person in any manner e so as to become subject to the Worker Compensation Lows ADDRE J�7C !J;P Z O V 11 Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT CONDO W I ARCHITECT OR TEL IJ Exemption TOA ICANT If after making Itis Certdic re of ENGINEER NO I W Examplton you should become sublet to the Workers CLASS NO DWELL UNITS_ N ,Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP _ with comply with such provisions or this permit shall be TEI deemed revoked , -- CONTRACTOR NLO BK PG 11, VALIDATION LICENSED CONTRACTORS DECLARATION LIC I hereby affirm that am licensed under provisrons of Chapter 9 ` ADDRESS NO VALUATION (commencing Section 7000)of Division 3 of the Business and LIC Professions Code and my license is in full force and effect Lt CITY CLASS $ Wa SO FT /� NO OF ND OF CHECK ' License Number L,c Class SIZE ll STORIES FAMILIES ONE Contractor NEW $ _ Date DESCRI ION OF WORT( O , I am exempt from the licensing requirements as I am a ADD ❑ licensed architect or a registered professional engineer ALTER FINAI QIO� acting in my professional capacity (Section 7051 REPAIR DATE 0 O Business and Professions Code) ,� USE OF �mOl _ EXISTING BLDG BY Lic or Reg No Dote APPLICANT TEL OWNER-BUILDER DECLARATION PRINT NO I hereby affirm that I am exempt from the Contractor s License _I _ Law for the following reason (Section 7031 5 Business and ADDRESS Professions Code) t, ` - - I, as owner of the property or my employees with BUILDINGADDRESS wages as their sole compensation will do the work and LOCALITY the structure is not intended or offered for sale(Section 0 7 0 0 A 7044 Business and Professions Code) MOVING r TEL , I as owner of the property am exclusively contracting CONTRACTOR NO # with licensed contractors to construct the project (Sec ADDRESS Icon 7044 Business and Professions Code) P e e 2 S 0 0 REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET eAac YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ® q D - e e * 25005 the performance of the work for which this permit is issued PL H (Sec 3097 Civ C ) - SIDE - 0 a 1,,0-81 PL Lender s Nome - i PC Fee S Permit Fee 0 Lender s Address I certify that I have read this application and state that the I Issuance Fee —70 above information is correct I agree to comply with all County Invesogouon Fee - 1 ordmancos and State laws relating to budding construction 14 i Total Fee and hereby authorize representatives of this County to anter uPon the ve mentioned or rty inspection purposes � �Q�,-�` ��,�^� I t SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of AppLc nt or Agent