HomeMy Public PortalAbout5441TEMPLE CITY BLVD_Building (2) A WORKERS COMPENSATION DECLARATION '
. I hereby affivn that I have certificate to self
insure, .�insure, w a certificate of Workers':.ome of carnomperuobimAPPLICATION FOR BUILDING PERMIT_
on insurance -
PERMIT-
or a certified copy thereof (Sec 3BOO, Lab C ) _ COUNTY OF LOS ANGELES- BUILDING AND SAFETY
Policy No Company.
❑ NG
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ,DDRESS
❑ Certified copy is filed with the county building Inspec WILDADDRESS. 5++ l Tei <£ G Bu/D
hon deportment
Date *- z-7-72-A-pplicant CITY f Ertl Lir GTT ZIP 9/7 O LOCALITY6.4
NO OF I LDL S NEAREST
CERTIFICATE OF D(EMPTION FROM WORKERS' SIZE OF LOT 6S Now ON LOT CROSS ST - -
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the permit Is for one TRACE BLOCK I LOT NO - MAP BOOT( I PAGE PARCEL
hundred dollars ($100)or leu ) I I TEL
OWNER KU, / MAP
8 -
USE ZONE
enify,that in the performance of the work for which this _
rmit Is asued, I shall not employ any person in any manner ADDRESS TEM E LVD 1140
SPECIAL NS T
w as to become subject to the Workers Compensation Laws _ 0
CITY TC tv T ZIP, / O
Date -Z7 ZApplicantiLke �CAO"(AV"A ARCHITECT OR TEL Cle
DIS IR GRWP TYPE FIRE PROCESSED BV O
NOTICE TO APPLICANT lf,_ making s Certificate of ENGINEER NO _ CONST , E G
Exemption, you should become subject to the Workers r y ,///, x I/ ri
Compensonon provisions of the Labor Code, you must forth- ADDRESS 1,J �O - IC -✓ Y
41)
with comply with such jNovrslorU or this permit shall be / TEL STATISTICAL CLASSIFICATION APT CONDO
deemed revoked �/ CONTRACTOR WN t10 - - ?
LICENSED CONTRACTORS DECLARATION UC CLASS No OZ� IswFli UNITS-
I hereby affirm that jam licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP "I
(commencing with Section 7000)of Division 3 of the Business UC
and Professions Code,and my license Is in full force and effect CITU CSS BK PG VALIDATION
SO FT NO 0 NO OF UCHECK
License Number Lic Class SIZE O STORIES FAMILIES ONE
vALuanoN rQTa. 750 1
Contractor Date ADD DESCRIPTION OF WORK NEW d
❑ I
s�sC-tom - ❑ =C-�• _a '_li
❑I am exempt under Sec Ise E3 � 45W ► _HNN�_E ,_I i
ALTER
B 8P C for this reason
REPAIR ❑ f
Data \ USE _
EXISTING BLDG DEMO( ❑ f_F it ij�I I'll'i q 1` 'p-
Signature
p-Signature APPLICANT TEL -
OWNER-BUILDER DECLARATION (PRINT) NO
I hereby affirm that I am exempt from the Contractor s License ADDRESS
Low for the following reason (Section 7031 5, Business and FINAL
ofeuio Code) . PRESENT - -_ By
as owner of the ro BUILDING >•
p perry, or my employees with Q ADDRESS
•tijl� <`cl'li
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section 1 LOCALITY -E
kC
7041, Business and Professions Cade ) 4`Js MOVING TEL _ �j 1. 1'EI I_
s owner of the property, am exclusively contracting CONTRACTOR NO �1 T� I I �I-
wlth licensed contractors to construct the project (Sec- • - • n ���
non 7014 Business and Professions Code ) ADDRESS /_ I F j
AFROMEXIST
CONSTRUCTION LENDING AGENCY IRED
SET BACK I YARD- IX
I hereby affirm that there Is a construction lending agency for FRONT
the performance of the work for whrch this permit is issued P L
(Sec 3097, CIv C ) SIDE
P L
Lender s Namery t '• f'I S _ 1 -7
IDMA Ref III-
PC Fee Permit Fee sJ 7�T `
Lender's Address /
I certify that I hove read this application and state that the s7 / Isuwnce Fee ��7�' (DMA.P/C•
above Information Is correct I agree to comply with all County nveaopotwn Fee _
o mantes and State lawn relating to building construction, Total Fee ��• LDMA Per N
< nd hereby authorize representatives of this County to enter
IYR /upon the above- a Ioned property for Inspection purposes --
P/T t _?7_ /L M @VERSE FOR EXPLANATORY LANGL_IAGE
&pnatwe of Applicant or A4ent Date