HomeMy Public PortalAbout5349TEMPLE CITY BLVD_Building WORKERS COMPENSATION DECLARATION 7/15_3/w LI n
here_1 um that I'have a certificate of consent to self
l`a ceWficate ofl Workers Compensation Insurance,
1 APPLICATION. FOR BUILDING PERMI
or o�prnf,eQ� A06
copy thereof (Sec 38M Lob C )
Policy No075� Company E �N� COUNTY OF LOS ANGELES BUILDING ANDS FETY
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
Certified copy a filed with the cou tiding mspec BUILDING ADDRESS
hon department ADDRESS EC G
Dotal— _Appbcant CI �� " ZIP LOCALITY t
s
CERTIFICATE OF EXEMPTIO N r �O NO OF BLDGS "'- NEAREST
COMPENSATION INSURANCE SIZE ff LOT NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR
hundred dollars ($100)or less ) /OWNER q�j USAWP BOC( PGEAPARCEL
`� LL E ONE '�
I certify that in the performance of the work for which this NO tvo
permit is issued I shall not employ any person in any manner ADDRESS S C .�I SPECIAL Cyt
so as to become subtect to the Workers Compensation Laws � CONDITIONS O
Dote Applicant CITY�� �G/ z ZIP It
NOTICE TO APPLICANT If after making this Certificate of 'NGIIt1BER OR L EZ N, / sJr DISTRICT UP TYPE FIRE PROCESSED By O
Exemption, you should become subject to the Workers �-/ � 3 CONST U
Compensation provisions of the Labor Cods you must forth- CRESS ��QG/UA of o J 0-
with comply with such provisions or this permit shall be CONTRACTOR t TEL
3 STATISTICAL CLASSIFICATION APT NDO Z
deemed revoked
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS—
I hereby aff rm that I am licensed under provisions of Chapter 9 ADDRESS E V eJeL NO SEWER
(commenang with Section 7000)of Division 3 of the Business and _ GQ mss.// C ,Q ��
Professions Code, and m license is in full force and effect CRY ��4VE�� li)Y - pIASS (s � VALIDATION
SQ
NO OF INO
License Number Lic Class ✓ SIZES STORIES FAAg�S ONE
oMA� Ceyy r 7-14 k NEW vnW TroN p/J
Contracto �- Date DESCRIPTION OF WORK / C .tJ" s v
ADD ,
1 am exempt under Sec T7 1 J
ALTER
B 8P C'for this reason REPAIR S
USE OF
Date EXISTING BLDG,A
Slgnatuns APPLICA19 eM O-�,S TEL FINAL
OWNER-BUILDER DECLARATION PRIM r ND FINAL
I hereby affirm that I am exempt from the Controclar s License ADDRESS f(J B L a DATE
Law for the following reason (Section 7031 5, Business andFtNAL
Profi sloro Cods) Ow BY
BUILDING
I, as owner of the property, or my employees with ADDRESS ,
wages as their sole compensation,will do the work and LOCALITY /J! ` �t 17 9 O A
the structure is not Intended or offered for sale(Section P� [i ,
7044, Business and Professions Code) MOVING �r4' yr} IL I • • e • 0,1
I as owner of the property, am exclusively contracting ( e,e 8 7 .3 8
with licensed contractors to construct the project (Sec- gpppEss L
iron 7044, Business and Professions Code) . t
CONSTRUCTION LENDING AGENCYffiBACK YARD HWY TOTALPRFROM!O'P SETBALINE WIDTH ExIST • is87386
I hereby arm that there is a construction lending agency for FRONT 7a 0 9 1 6—8 7
the performance of the work for which this permit is issued P 7 _ -
(Sec 3097 Civ C ) SIDE `
PL V
Lenders Name
$ LDMA Ref 0
Lender s Address PC Fee S Permn Fee :74r poll"
certify that I have rood this application and state that the Inuonce Fn LDMA P/C•
obove tnfor ion a correct I agree to comply with all County Inves--Fh Fes -
ordtrwnc d Stare Iowa relatmg to budding construction Tool Fee TDMA Perm Y
and nut ae rept seotat vee of this County to enter
upo abs pro for inspection Purposes
Y UK RKVB FOR EXPLANATORY LANGUAGE
u of Applicant Date