HomeMy Public PortalAbout5340TEMPLE CITY BLVD_Building WORKERS COMPENSATION DECLARATION ;
CJ
hereby affirm that I have a certificate of can,en*nc ,elf_ — APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers'Compenshon Insurance or "
a certified copy thereof (Sec 3800 Lab C ) -- - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished — FOR APPLICANT TO FILL IN BUILDING S3 O
ADDRESS
Certified copy is filed with the county building mspecING _
tion department ADDREBUILDSS LOCALITY
RE
Dote Applicant CITY ' ZIP Sd CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS NO SIZE OF LOT - _ NOW ON LOTS MAP BOOK PAGE PARCEL
i S ASSESSOR
COMPENSATION INSURANCE
(this section need not 6e completed if the permit is for one USE ZONE MAP O
TRACT BLOCK LOT NO
hundred dollars ($100)or less ) NO
_ ! /t TEL i I SPECIAL
I certify that in the performance of the work for which this OWNER C NO CONDITIONS CILO
permit is Issued I shall not employ any person in any manner /+ DISTRICT GROUP3 TYPE FIRE PR SSED BY L.7
so as to become subject to the Workers Compensation Laws ADDRESS �� 6rc Cs7 CONST ZONE cc
PPlicant
- - 5,eY' IC- �/
Date-Applicant CITY ZIP O
OO
APT CONDCT
NOTICE TO APPLICANT If cher making this Certificate
CLASSIFICATION c
cate of ARCHITECT OR -. - TEL W
Exemption you should become subject to the Workers ENGINEER NO r CLASS NO C� DWELL UNITS 911.Compensation provisions of the Labor Code, you must forth ADDRESSSEWER MAP =
with comply with such provisions or this permit shall be
deemed revoked TEL - VALIDATION
CONTRACTOR• NO BK PG
LICENSED CONTRACTORS DECLARATION LIC _
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS _ - NO - VALUATION
(commencing with Section,7000)of Division 3 of the Business and ^'-•�q /
Professions Code and my license is in full force and effect CITY LIC LIC S
SO FT NO OF NO OF CHECK
License Number be Class SIZE STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK NEW ❑ S 1
❑ I am exempt from the licensing requirements as I am o ADD ❑
licensed architect or a registered professional engineer - ALTER ❑ - FINAL
acting in my professional capacity (Section 7051 DATE
Business and Professions Code) REPAIR
USE OF NAL
EXISTING BLDG DEMOL ❑ FINAL
Lic or Reg No Date APPLICANT TEL By
_ --
OWNER BUILDER DECLARATION PRINT — NO -
I hereby affirm that 1 am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESS
Professions Code) RESENT `
❑
I as owner of the property or my employees with BUILDING
ADDRESS
wages as their sole compensation will do the work and
the structure is not Intended or offered for sale (Section LOCALITY
7044 Business and Professions Code) MOVING TEL
1 as owner of the property am exclusively contracting CONTRACTOR _ NO - 3 3 3 Q A
with licensed contractors to construct the project (Sec ADDRESS
hon 7044 Business and Professions Code) I -
REQUIRED TOTAL SETBACK FROM EXIST ' # ,�
CONSTRUCTION LENDING AGENCY SET BACK YARD HVIY PROP LINE WIDTH
1 hereby affirm that there is a construction lending agency for -- -- FRONT 2 • • 8 5 Q
the performance of the work for which this permit is issued PL
(Sec 3097 Civ C ) - _SIDE •_ _ _ _ _ _ • • • 8 50 U
PL
Lender s Nome 0 3 22-82
_$ Lander s Address PC Fee$ Permit Fee '
b I certify that I have read this application and state that the Issuance Fee r
above information is correct I agree to comply with all County Invemgation Fee ry
ordinances and State laws relating to building construction Total Fee
and hereby authorize representatives of this County to enter
upon t above-mentioned property for!Aspechon purposes -
t v �r /q d'aZ - SEE REVERSE FOR EXPLANATORY LANGUAGE I
^ Sign/.r.of ApplLmni or Agent Dote cps