HomeMy Public PortalAbout5448TEMPLE CITY BLVD_Building (2) APPLICATIONS FOR BUILDINLG DING PERMIT
COUNTY OF LOS ANGELEAND SAFETY
WORKER'S COMPENSATION DECLARATION' A FOR APPLICANT TO FILL IN r EllaOaq
I hereby affirm that I have a certificate of consent to self Insure BUo.pNG E
or a certificate of Workers Coinpensaton Insurance or a earthed CITY 1
copy thereof (Sec 3800 Lab C) ZIP LOC+vLrtY
Policy No Company SIZE OF LOT , OF BLIX'9 NOW ON LAT
13 Certified copy m hereby furnished C` NEAREST CROSS
ST
❑ Certified copy is filed with the county building inspection TRACT \ . BLOCK LOT NO
department - USE ZONE MPP NO
Date Applicant _ - - ASSESSOR AMP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN 1000 FT of SCHOOL' YES NO
(This sector reed not be completed If the permit is for one hundred ADDRESS
DISTRICT GROUP TY CONST FlRE ZONE P}iOCESSED 81'
dollars($100)or leas) Cm' I iZIPI Gersh, that in the performance of the work for whch this perms N <.4,1 -�C
Is issued I shall not employ any person In any manner a to 3
become 91 the Workem Com ARCHITECT OR ENGINEER TEL NC
SUTISRCAL C��LLq�77Sff//77 ON APi CONDO
Date 00 —t ADDRESS CLASS NO DWELL UNITS
M077CE TO APPLIG1NT If er making this Certificate of REWIRED TOTAL SETBACK FROM EXIST
Exemption you shoud become subject to the Workers TEL NO SET BACK YAR) HWY PROP LINE WIDTH
Compensation prowsons of the Labor Code you most forthwith
FRONT
comply with such provsens or this permit shill be deemed revoked AL NO PL
LICENSED CONTRACTORS DECLARATION a 33/ SIDE
CITY H LIC,�QtIS P L
I hereby affirm that I am licensed underprovrsens of Chapter 9 4Z L SEWER MAP
(commencing with Section 7000)of Division 3 of the Bualreas and SO FT SRE NO OF STORES NO OF FAMRIES
Professions Code and my license s in full forceact I NEW EK PG Poo.Llcen a/IN be Clea. �� DE OF WORK ADD 13 VALUATION Nbo
ALTER ❑ �$ I BdO.
El am exempt under Sec REPAIR ❑ $ 1 Q
BSPC for this reason DEMOL ❑ PYO AA//vv//vvT y IIII Date USE OF EXISTINGORLD0 URM ❑ glgAy,r - 108.900-
Signature APPLICANT(PRIATI TEL NO LDM1A Perm• Z
❑ 1 as owner of the property or my employees with wages asZO 1 ITEMS
their sole componsatlon will do the work and the structure s ADDRESS w�
net Intended or offered fa sale (Section 7044 Business and FINAL DATE -'9 TOTAL 108 . 90
Professors Code) coni THE,.wucwr OR FuneE WILEXhe occwwr uwnLe A w�zu S WTER _ - 7 ��w�e�.uI�
❑ I as owner of the proper am exclusive contracts with OR A MxnmE couDSNa+D A Iwxpous MATERIAL Lo To OR GREATER THAN THE CAM 108.90
property N ng AMGMTa SMO RED ON THE HAZAADOUa MATF3AALs INPORIMMO14 GUIDE? FINAL Bq
nu.ulrr
bccontractor, to contractotO construct the protect (Section 7044 YE9 El re 11 (#ISE .00
Business and Professens Code)
WILL THE MENDED USE OF THE BIYDDNG BY THE APPLIOWT OR FUTURE 111 D
OIXxIMm REOURE A FERIAIT FOR CONSTRUCTION OR MODFIOQpJ FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAsr AA Qu MANAOEAENi Diel Iscrp"°1 sEE MER"^'"e CHECKUs FOR yv�LyMawMv� p Ny1.�,
WS13 - 1//7 11 M1/� �
Ihereby-affirm that [here s e construction IBndlflg egercy for rs❑ „p❑
ry the performance Of the work for which tons permit its Issued(SeC IHAVEnEAO THE HAZMDOUS IMTEWILe NFCPoAATX)N WIDE ANDTIE eCAp.OPETMTTINO
m 3097 Civ C) GIEU'QL4T lM)ERSPM Mr REQAREMENB uICER THE 1119 NICaEI.Es cauNTY CCCE
TIRE 1 CHAPTER 410 SECTIONS}10 100 TIAOII(AI]40 IAD CCNCERNNp I VSMDO.N
Lenders I`Lan1B MATEnW 9 REFORTW AND FIXi O6➢I!A!e A PEfAQT FTpM TIE 9CIpAD
O Lenders Address
O CM.EF OI.6N!
1 certify that I have read the application and FEE
state under perWty PC FEE PER
8 of penton, that the,bore information IS CaTBCt I agree to conpNy MIT O
$ with all county ordinances and State laws relating to hllldlflg
S cons uggn and hemtyy authonZe representatives of this County ISSUANCE FEE 9..
to enter up ve- red prope Glen purposes
m /�4��N✓-�f INVEMWT10N FEE TOTAL FEE
�I bb NY
SEE REVERSE FOR EXPLANATORY LANGUAGE