HomeMy Public PortalAbout5235TEMPLE CITY BLVD_Building (2) I
WORKERS COMPENSATION DECLARATION
hereby affirm that I have a cerl.f.cote of consent to self APPLICATION -FO -BUILDING PERMIT
insure or a certificate of Workers Compenstion Insurance or
a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company 11
BUILDING
-�- Certified copy is hereby furnished the cd - FOR APPLICANT TO FILL IN ADDRESS
Certrfied copy a filed with the county building mspec BUILDING
J ttan depar ent ADDRESS 2 Temple Cit Blvd . LOCALITY Temple City, Ca . 91780
Dote -3/3 / 1.Applicant CITY ZIP cROsssT Blackley
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR t
I COMPENSATION INSURANCE SIZE OF LOT 130-x 228 NOW ON LOT. - 2 MAP BOOK PAGE ARCEL
i6 (This section need not be completed if the permit is for one I USE ZONE MA
I t.t hundred dollars ($100)or less ) - - - - __ _ TRACT BLOCK _ - -_ LOT NO -- -- - NO A, ?O Y
certify that in the performance of the work for which this OWNER Mis O it 1'1 NO 287-860 SPECIAL��/ CONDITIONS v �0 /
permit is issued I sholl not employ any person in 6ny manner - DISTRICT GROUP TYPE FIRE SSED BY V
so as to become subject to the Worker Compensation Laws ADDRESS9587 L8 Rosa Dr. r n p �s� CONST / ZpWS
Dole ApphmCITYTem le Cit Ca - ziP 1 80 VO
nt STATISTK-AL CLAS$L�,fCA ON / APT , CONDO ` W
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR, - TEL p p �`)
k ENGINEER NO 28 -86 CLASS NO DWEU UNITS_ d
Exemption you should become subject to the Workers N
Compensation provisions of the Labor Code, you must forth ADDRESS 9587 E. La ROB$ Dr SEWER MAP - Z
with comply with such provisions or this permit shall be �s
,deemed revoked CONTRACTOR tNj Lp 4 BK PGS/ VALIDATION I
LICENSED CONTRACTORS DECLARATION 5p L8 RO$8 Drz LIC
NO
L hereby off um that I am licensed under provisions of Chapter 9 ADD VALUATION -
(commencmg with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect _ CITY ' l CLASS S
SO FT _ NO OF NO OF CHECK
License Number Lic Class SIZE ISTORIES IFAMILIES 1 ONE
� S
ContractorDafe I DESCRIPTION OF WORK demoliBh bl d NEW El
ADD
am exempt from the licensing requirements as I am a ❑
I- licensed architect or a registered professional engineer FINAL
acting in my Professional capacity (Secon 7051, REPAIR DATE
� -
`` Business and Professions Code) USE T -
1/ ExIBTING BLDG O � DEMOL ❑ FINAL �
t Lic or Reg No Dot.. APPPRIINTT MISAO HIROHA N0628-12 4 8T
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License 8 I
_ Law f the following reason (Section 7031 5 Business and ADDRE
Prof ions Code)
I as owner of the property or my employees wnADDRESS
BUILDING5235e
wages then sole compensation will the work and
LOCALITyTemple C ity , Ca.
- the structure
f ,
is nor intended or offered for sale(Section - ,
7044 Business and Professions Code) MOVING, TEL
1 as owner of the property am exclusively contracting CONTRACTOR - NO 4 5 8 2 A
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) # • • • • • 1
REQUIRED
CONSTRUCTION LENDING AGENCY SET BACK YARD HWv TOTAL SETBACK FROM EXISTPROP UNE WIDTH 21- a 3 7 0 0
- I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued PL i
(Sac 3097 Civ C ) _ SIDE • • • 3 7 0 0 d
P
Lender s Nome L 0331 -�i 1
Lender s Address
8 PC Fee S Permit Fee ,�O/69-0
_ t
I certify that I have read this application and state that the Issuance Fee "
above information m correct I agree to comply with all County __ Investigation Fee - ;
ordinances old State jaws relating to building construction Toiol Fee � / 1
C and hereby authorize representatives of this County to enter
< upon the above mentioned pm Iy for inspection apos
x$
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Doi