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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