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HomeMy Public PortalAbout5349TEMPLE CITY BLVD_Building (2) ,APPLICATION FOR WILDING PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO RLL IN MBIIILDI ADDIiE33 I hereby Idn that I hie a certificate of consent m aeh Insure eul a a certificate of NbrkeerreC�ommy/peensat on InSurarcs,a s Certified lw t �) �L�D. coy No / J�G'I /�Gornpany 2D.1 �lll�J7 Zip LOCALITY SIZE OF LOT NO OF BLDr NOW ON LOT 0 r.�lp„r copy13 hereby�I�ed NEAREST CROSS 3T — Certdbtl Jz ts filed the Cat WI I nepection TRACT BLOCK LOT 110 USE ZONE MAP NO DaOedef � ICel1t ILIP BOOKIO� 15-- PARCEL —/ SPECIAL /KTIONS — CERTIFICATE OF EXEMPTION FROM WORKERS' x' 70 YES NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? (Thar section rood not be canpbtl d lethe permit is for ADDRESS for ohundred S E fe f{"LJO�E DISTRICT GROUP CONST TZONE In' dollars(1700)a Ives) CITY ZIP 4 I Certify Cmt m do performance of the work for which thio permit , m meius4 I shell not employ any person In any manner ac as to IFlFFl7 713.NO STATISTICAL ICATKNI APT CONGO become subject to the Nbrkers'Compensation Lowe 7 Date Applicant ADDRESS rtl NO _DWELL UNITS NOTICE TO APPLICANT If. after making this Certificate of CdkTRACTORREGUstm TOTAL SETBACK FROM EKIST Exemption you should become subject to the Workers' "� SETBACK YARD HWY PROPLINE WIDTH Calnpeneatiun pro futons of the Labor Code.you marl IorNwIN 044 FRONT comply with such proWekxm or this permit ahall be deemed revoked S A_ / r e n w12f4PL LICENSED CONTRACTORS DECLARATION f 11V 1^ '-•Cj`�� _LI SIDE p}, n� PL I hereby affirm that I am hcwmd under provisions of ClMpter 9 K my LPr SEWER MAP (cornmerlCing with9BCiWn MW)o1 DMsion 9 of the BressummW R5 NO OF ILI STORES NO OF FAMES Profassbrm Code, my Is in fug face effect FT BILE — 1/- NEW ❑ SK PG popLhCense Number LIC Claes DESCRIPTION OF WORK ADD B' VALUATION Contractor Dots 9/ ALTER 11 _ / Q d - ', - ,` - F - j ,j ❑ I am exempt under Sec REPAIR ❑ $ ,I •1 ` B BPC for tits reason DEMOL ❑ LOMA Pica Date USE OFEWsnNG M URM ❑ SignaturSignature ZPPIZ CDMA Rim ❑ I as owner of the property, or my employees with wages As q O their sob compensation, w it do the work and the Structirrs m not Intended a offered for mb (Section 7044, BuMnma and ��k 1 PTOlere101m Code) WILLTIEAPPLICANT fUn11�8W.DWU000LN,NT1MM0.rAH�SARDO11e WTOVK I OR A IQIIlE aro A yAT98AL FllllAl TO Ori OIEATEA TIMR , ^j T 1 ❑ I ar owT,er of the property, am exclunveiy contracting with TIE AIKIIMrs aPE "Im ON TXEIWA1mOUr YATanMlr 116aa1ATlON ohADE9 FIMAL > h ACCT.It licensed! contractors to construct the Business and Pmlmaam Cade) protect (Section 7044, res❑ w ` _ ' j,hi 17 17. wu TME n+rao®,�•�ua���E uawwarrrTrrr000Ennns���lla.owc er TIr.Awucurt ca runn¢euaneK+ �� p ;I CONSTRUCTION LENDING AGENCY Fan���ns ice)SER T a` corer&R ouum wTmcT I hereby affirm that then m e construction lending agency for sea❑ No �r3� LLv,,tt \ the performance of the work for Which this permit Is Issued(Sec1 9087.Ch,C) h RTW TIE w nmh Glum ceah MIDTHE�� a LendeYs Name ' TIEecnuo Lendare Address a. 7 / I Cer*that I hie read this appik ebw and a"that the above PC FEE PERAtrc FEE Information is cored ague to campy wltil ell county ordmances State ng 0 buhktsq cormtruction,and A Q auth sof this Cwmy to,enter pun ISSUANCE FEE !3 INVESTIGATION FEE TOTAL FEE �j C.2 7 BEE RerlRse FOR OtPEXPLANATORYLANGUAGELANGUAGE 'f.