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HomeMy Public PortalAbout5438TEMPLE CITY BLVD_Building (2) WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to ,elf APPLICATION FOR _BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, -- or a certified copy thereof (Sec 3800, Lab C) - COUNTY OF LOS ANGELES BUILDING AND SAFETY - - Policy No 10`41Company ❑ Certified copy is hereby furnished �� 9/ FOR APPLICANT TO FILL IN BUILDING' ADDRESS •© Certified copy a filed with the county building Inspec- BUILDING / ' ,B�j! tion department lG Applicant 0Ar.PaKA+ Qoylii � Cry ra a eNEAREST LOCALITY CROSS CERTIFICATE OF EXEMPTION FROM WORKERS " SIZE OF LOT - NOW ON LOT- - Date to_2-3- Cl1 S _ CROSS Si COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACTBLOCK ^ LOT NO- MAP BOOR -- PAGE PARCEL hundred dollars ($10)) a less ) OWNER S//'sv TEL USE ZONEt MAP I certify that in the performance of the work for which this p�✓� L, SoEOAL a Permit is issued, I shall not employ any person In any manner ADDRESS 3 6 CONDrnary5 ' O so as to become subject to the Workers Compensation Laws - _ ,. U CITY ZIP OZ Date Applicant ARCNI OR TEL DISTRICT .vGRWP TYPE FIRE SSED BY Q NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO _ G CONST Z E V Exemption, you should become subject to the Waken `QU :3- � �+ Compensation provisions of the Labor Code, you must forth- ADDRESS N with comply with such provisions or this permit shall be STATISTICAL CLASSIFICATION _ . APT CONDO Z deemed revoked t, CONTRACTORNO U LICENSED CONTRACTORS DECLARATION 6$r D� /'r9L r CO 3�7 OA-ss NO DWELL UNITS— LICENSED hereby affirm that I am licensed under provisions of Cl opter 9 ADDRESS_ LIC SEWER MAP (commencing with Section 7000)of Division 3 of the Business ,oO CLASS VALIDATION and Professions Code,and my license is in full face and effect CITY_ CI N _ _ NO OF NO OF _ CHECK BK FG License Number 5141 L7 Llc Class G-735 SIZE STORIES FAMILIES ONE _ VALUATION Contractor CA1i� 01 ,211-91/A' Date DESCRIPTION OF WORK NEW © $ �8 t70 ❑ El lop.am exempt under Sec _ r ALTER ❑ B&P C for this reason clr REPAIR ❑ $ Date USE OF _' DEA10L ❑ EXISTING BLDG SignatureR �A PINTL EO i3jJL FINAL , OWNER-BUILDER DECLARATION DATE 1 _ I here affirm that I am exempt from the Contractor s License - f�-(T.' Law for the followag reason(Section 7031 5, Busmesi and ADDRESS ��y� FIN Professions :,J Code) _ _ SENT _ _ _ _ By- "(1 BUILDING S � /Q.... ❑ I, as owner of the property or my employees with ADDRESS wages os their sole compensation,will do the work and ' • • - - O„ - I ��EMC - the structure is not intended or offered for sale(Section LOCALITY A 7044, Business and Professions Code ) - MOVING _ TEL _ _ , 1( , - OTAL 70 Jar ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO I` FE u - Ii 'IJ._C with licensed contractors to construct the project (Sec- - ADDRESS - tion 7044, Business and Professions Code ) CHANGE CONSTRUCTION LENDING AGENCY SET BALD YARD HWY AL IN E WIDTH FROM I T _ _ _. _ t I hereby affirm that there Is a construction lending agency for FRONT _ the performance of the work fa which this permit is issued P L (Sec 3097, Civ C) - SIDE PL - 5447 1 AMILID:01 Lender's Name Il TDMA Ref I ^ _ PC Fee f Permit Fee oil. ' Lender's Address I certify that I have read this application and state that the issuance Fee � ( tDNA P/C Y above information Is correct I agree to comply with all County _ Investigation Fee / _ i ordinances and State laws relating to building construction, total Fee �• 0 LDAM Perm I I and hereby authorize representatives of this County to enter upon the abo en d property for inapeclion F{yu�r)pos�es _=2)" y/ _ - SEE 16VERfE FOR FJ(Pl/1MA70[Y LANGUAGE Signature of Applicl Agentto , v