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