HomeMy Public PortalAbout5339TEMPLE CITY BLVD_Building (2) 'r
APPLICATION FOR %1k ILDING PERMIT
l COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN etxallo +
I hereby sftmm that I have a ceridpate of cpnaent to sell malas BUILDING AOIXiE93
or a certificate of Workers Compensation Insurance or a certifiedBL-
copy thereof(Sec 3800 Lab C) C7Y
ZIP
Company7 A-H At C �� 91710 LocALrrY
91ZE OF L T NO OF BLDGS NOW ON LOT
❑ Cerlred copy *,hereby furnished NEAREST CROSS ST
❑ Certified copy is filed with the county bwic irg Inspection TRACT BLOCK LOT NO '
department I I USE ZONE IMP NO
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONWONS
OVINNER TEL NO
CERTIFICATE OF EXEMPTION FROM WORKERS' YES MA-1017 8/P-383 -3�CY wTTNN +coo FT OF scNoaL+ YES No
COMPENSATION INSURANCE
IThke sector need not be completed it the permit m for one hundred ADORES r
dollars ($I DO)or lass 1 6"3j7 DISTRICT GROUP I TYPE CONST IFIRE ZONE PROCESSED BY
TY
I Dertmly, that in nce the performaof the work for wh ch this permit G-r-rsir !ic �T� LP�Y
M ISSUed I shall not employ any person in any manner iso a9 to ARCNITE OR ENGINEER` TEL NO
becprte BUbpOt 10 time Workers Compensation Laws STATISTICALFfWCONDOT10N APr C
Date Applicant ADDRESS .. CLASS NO DWELL UNITS
Ni ID APPLKANT It after making the Cerbficate of , REQUIRED TOTAL SETBACK FROM EXIST ,
Exemption you slWd became subject to the Workers CONTRACTOR TEL NO SET BACK YARD MVY PROP UNE WIDTH
Camperoatlon procto of the Labor Code you must forthwith L-f l�LJ
comply with suolm proems ons or this pefmt shall be deemed revokedADDRESS LIC NO FFR NT Y
a.
LICENSED CONTRACTORS DECLARATION CITY , LIC CLASS sPIOl. - O
U
1 hereby affirmw that I em 000)o undsion 3 of iTs�olthe B Chapter S SEWER MAP I �.
(panmefpsg o with Section 7000) ra Division 3 a the BU9xe8e and 90 FT S/IZiE/� NO OF STORIES NO OF FAMILIES NEW SK PG 0
Professions Code and my Ilcen9e a In full lorce and eNact x! T _ I—
Lpense Number 1-c Class
DESCRIPTION WORK ADD ❑ $ a te.BQ , a
Contractor Date L _ ALTER ❑
T Z z
❑ 1 am exempt Under Sec REPAIR ❑ $
BAPC for this reason10 DEMOL 13LDMA P/C•_ ,
Date USE OF EXISTING URM ❑ , r 1
SgietUre APPLICANT(PRNT) TEL NO LDMA Perm• . ACCT.i
I as owner of the property or my employees with wages as QZ I
their sole compareshon mU do the work and the structure a ADDRESS FINAL�� F 3303 125.55
not intended or offered for sale (Section 7044 Business and T 9 IQ �I�}�+
Professions Code) wlL THE APRLIf.IJtT On FU U,%e11DIN pCGlnlhn W A IULJpale MREWAL .. '1 ITEMS
❑ I Be owner of the property am exclusively contrecll wmtlm oR A W TU cpNpeee A NAZArpare AWTERAL EQUAL TO of G TER T0N TNs TOTAL 1.�-1 C
_5-
A4pLelTs ePECFTEO ON THE IMSAIiDOUa AWTERNL4 KORMAT)0N GUM, FINAL 2 8Y ,O C
licensed contractors to construct the proleCl (Section 7044 ❑ NO❑ ,
Bmwas and Professions Code) VAU
Till 1HE MEWED 119E A TME BlA011he BY TIE APPIIGWT Oji F FROM
T eLlOfe CHECK ' 125.55
WQUtRE CONSTRUCTION LENDING AGENCY O0&3T Rs Y A RERi,11i Faa STWT isChO a+x rte N FWM THE sarin CHANGE .00
GUIDE AA aMUTY LWNGEi.ENT a9TFppT 19CApMU1 SEE RERATT41p a1EGalST FOmi
I hereby affirm that there is a conetnpton lending agency to No ' _
the Perlormence of the work to which this permit a issued(Sec YEs❑ ❑
' "K"R°°U9M„TE'EH9"°Ri„''""'°UIpE"b'1E SGpxp PER"T'"° 0000—W(KT
01 - 4/15!96
3087 CN C) oEnxlsT I LwpERsr IA'REDUREIAENTe u R THE Las A UHS COUNrr cceE
Lenders Name Mraw.s MPORTirm uo`TFo 'ore aiaODio A rt vRI140
oM scAaM OD A�""n0O 9 `w°bP 1 AN 9:19
Lendera Address `
CY/KN U.RMT
I certify that I have read this appl"h n and state under penalty
of penury that the above Information Is correct I agree 10 comply PC FEE PERMIT FEE a
m� with all ccunty ordmences and State laws relating to building D
di owstnic on and hereby aWlpnze mpreseNatses of the County ISSUANCE FEE
to enter Upon the above m�enhorn d property for mspedw purposes
NVESTIGAT10N FEE TOTAL FEE / i - •• _1 • '
SEE REVERSE FOR EXPLANATORY LANGUAGE