HomeMy Public PortalAbout5417TEMPLE CITY BLVD_Building (2) WQRWS' COMPENSATION DECLARATION,i1 �.r
1 Mreby affirm that I have a certificate of consent to self APPLICATION F6 IR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec 3800, Lob C) +
• - COUNTY OF LOS ANGELES . - BUILDING AND SAFETY
Policy No Company
ElCertified copy a hereby furnished FOR APPLICANT TO FILL IN ADDRESSBUILDI
tion
S L//7
❑ Certified copy is Bled with the county budding inapec- AD�ESS S t /7 C/ L 1.f� C7 C/� l� � Q
tion department
Date Applicant Ory C- CdAIP � LOCALITY
NO OF BLUG5 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT - - NOW ON LOT CROSS ST -
COMPENSATION INSURANCE -
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO M,AP BOpc S r, PAGE OZS PARCEL mC
hundred dollars ($100)or leu ) I ,}
't OWNER L[� ICC -h10 -/ USE ZONE ASAP
I certlfy that in the performance of the work for which this '7 (o
permit is issued, I shall not employ any person In any manner ADDRESS C., L ��� CONDITIONS
d
ao as to become subject to the Workeri Compensation Laws O
CITY •e
4e �/ IP
Dote Applicant ENGINEER
II�OR hO DISTRICT GROUP TYPE IRE Y K
NOTICE TO APPLICANT If, after making this Certificate of - CYNJS,''{/y_ E O
Exemption, you should become subject to the Workers' S.Og y
17)
Compensation provisions of the Labor Code, you must forth- ADDRESS V
with comply with such provisions or this permit shall be .L _ TEL STATISTICAL CLASSIFICATION APT Z
deemed revoked CONTRACTOR N -�.v -'
LICENSED CONTRACTORS DECLARATION UC CLASS NO oZ/ r DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO - SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC
and Professiom Code,and my license is in full force and effect CITY CLASS BKFG/.;L- VALIDATION
50 NO OF J NO OF CHECK _ -
License Number Lic ClassSIZE STORIES ( MV
FAUES ONE
VALUATION
Contractor Dot
' DESCRIPTION OF WORK _ NEW El O
►
e ® j G
❑1 am exempt under Sec _ ADD
ALTER ❑
B 8P C for this reason REPAIR ❑ $ _
Date USE - _ O - DEMOL 171 -i
EXISTING BLDG
Signature APPLICANT TEL W FINAL
OWNER-BUILDER DECLARATION jPRINTI 9 NO DATE
I hereby offnm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5, Business and ADDRESS FINAL `
1Pjrro�oLfeuions Code) — _ - - By
L2} I as owner of the property,-or my employees withADDRESS NG 5 -C� L yt`\ j r �; - I�� fv a?r
woges as their sole compensation,will do the work and L«,��, P l { CP L / 6 -R.r ., r
the structure is not intended or offered for sole(Section MOVING TEL 3-W4�I•J�S it-� 1��1�
❑ 7044, Business and Professions Code )
1, as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS
tion 7044, Business and Professions Code ) p� EXIST
r1. �`^sal-1r '+LL•_4
CONSTRUCTION LENDING AGENCY SIRED YARD HWY ALPROP LINE I WIDTH
FROM I
I hereby affirrn that there iso construction lending agency for FRONT
_ l
the performance of the work for which this permit a issued PL 1 To_AL 477; :5c
(Sec 3097, Civ C ) SIDEr_
PL •R_HE /h IJ._
Lender's Name N.
TDMA Ref N ' ��HAhIGa: _ .�ltl
PC Feet VALE— Permit Fee Q
Londe/s Address �1
ertify that I have read thwapplicwnon and state that the laaance Fee 1 -les LOMA P/C N _ r„
vis
information is correct I agree to comply with all County In~,gaaon Feeq 1-Ill_IQ—i ISI 1 =✓J 1 _
ha
noes and State laws relating to building construction Total Fee L LDMA Perm E ?^75 t Neil'Sr
y authorize representatives of this County to enter
ve- nti/p/7d^Property for inspection pyrpc7m I
Sit REVMIA FON EXPLANATORY LANGUAGE _
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