HomeMy Public PortalAbout5450TEMPLE CITY BLVD_Building ` ARPLICATION FOR BUjLPING PERMIT
t . COUNTY OF LOS ANGELES BUILDING AND SAFETY r
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN Bu '
I hereby affirm that 1 have a certificate of consent ,o self Insure Bl1ILDPlO
or a certificate of Workers Compensahon Insurance or a combed
copy thereof(Sec 3800 Leo C) ZIP �Q LOCA
Policy No Company SUE OF LWr NO OF SLUGS NOW ON LOT
❑ Certdied copy a Hereby fummhed NEAREST CROSS
ElGtrhfied copy a filed with the courtly bullduq mspectKm TRACT BLOCK LOT NO
departmentAGE T USE ZONE MPP NO
Date Applicant AS. SSOR d� •.� OL1S SPECIAL CONDITIONS -
CERTIFICATE OF EXEMPTION FROM WORKERS Q R c� TE TEL NO �8,'J� YES
No
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? ,
(This sedKKK reed not be completed R the permit a for One hundred 4 ESS
\I,�J e /D PG1 DISTPoCT GROUP TYPE CONST REZONEtR
driers($100)or lase) � h _
I certify that In the performance of the work for which this permd \A+ qJJf? �QO .O1 _-3 //Ls issued I shell rot employ arty person In aty manner iso es to � -,4become subject to the Workers Co peroonm Lawi AJRQHRECT E NEER',D/►I & TEL 3�33d0 SATISTICALCLA^SSFI'T"' ADate Applicant ADDRESS l• CLASS NOALDWELL UNTIs 74-1NOTICE TO APPLICMT II after makuq this Certifcato of ' epV�/� REQUIRED TOTAL SETBACKExemption you should become subject to the Workers CO NO SET BALK YARD MVIY PROP UN
Compersabon provIslonv Of the Labor Code you must fort= Cr Oma✓ S/T O rJ FRONT ,
comply with such pro+eiorns or the permit shall be deemed revoked ADDRE P L
SIDE
LICENSED CONTRACTORS DECLARATION C r OQ P LIn
1 hereby affirm that I am licensed unceTprovecrm of Chapter 9 r r SEWER MAP
(commorri with Section 7000)of Emmert3 of the Business FT 912E NO OF STORIES NO OF FAMIlES NEWBK D PG ��. ACCT.`.
Professions Code and my license e m full force and effect , 3303 1715.6E
License Number LK: Class OESCRIPTLOMOF_WOmW ADD ❑ VALUATTONp 1 ITEM
IS VVY
Cantmctpr Date �, ALTER ❑ $ Q 7 ,,
TOTAL 1715.6E ¢
❑ 1 am eXempt under Sac REPAIR ❑ $ CHECK 1715.680
BBPC for this reason DEMOL ❑ LOMA P,C• CHANGE ,00 1�J
Date p USE OF EXISTING BLDG URM 11 lop
Sgreture % Z_
V APPLICANT DMA Pa
NT(PRNTI TEL NO Lm• 1
111 as owner f the property or my employees with wages as O .0ev�n_�n11000 M1 10/ 3/95
their sae compensation wit do the work and the structure a ADDRESSF ,y,7Qb 1 iqE
not intended or offered for sale (Seals 7044 Business and FINAL DATE v- �' G _ j
Professions Code) NTLL TIE APgJGM oa Fl1ME euAONo OCCWWT IVJIOIE A HAZArWIIS WTERNL .q a w, �,1 ITEI IJ
�I 89 Owner of the property em 8%Cjusrve contrectug with OR A MIXTIRE COWN1010 A II/SAIiDOIB MATERIAL Ea To OR GREATER THAN TIE
H AMOINTe ePECIFEo ON TIE HAZARDDLS WWRI LS KORMATICN GUM' RNAL BY � 7 O
licensed contractors to construct the project (Section 7044 YEs❑ ,io❑ TOTAL 174.98
Bksmess and Professions Code) COCK 1742.9E
wTL TIE NTEWED USE OF TIE Wei BY THE Af4LKAlm OR rlJT1.1E BUI DNa
OCCLPAM REOINE A FERIRT FOR CCNSTRUCTgN OR MW 710N Fq^M T SOIRH 0t�i >
CONSTRUCTION LENDING AGENCY G6V`T AR owuTY WnkfY1.EHT pests 19LAOI.0)BEE PEAI.wTTINe LIECKUST FOR r✓'�l i 1 j,CHANGE ,00
OI.t]EUHEs A OV /. jg
I hereby affirm that there s a crnstructerK lending agency for s❑ Np❑ l/V1� T� v,/�{ .l K
the performance,Of the work for which the 1ermR a owed(SBC SAD THE HAZAADOU9IMTERYL91NfORMATICNOIIDE AHp THE 9CApOPERtaTTIe
0 3097 civ C) QEIXW^I 11IlprRBUfD Ary REaLSESENis NlIEP TIE LDe AROELEs COIIHTY CODE �� , ' 0000-0001 12/26/95
Lender a Name W gKeCluvTER a�aO� C R 6TUNI G A FRpOI.KI T1E At�I1S
0
Lenders Address
3919 1 Afl11�17
certify that I have reed this application and state under penally
g
of perjury that the abovo fRofmotion Is coned I agree t0 comply PC FE PERW FEE
$ with all county ordinances and State Iowa relating to buikhrig '
ooretructlon and hereby audlonze representatiies at this County ISSUANCE FEE ,y
lo e 1 J on the abo rt,Xmed property for mleachon purposes zJ` 7 3 D
INVESTIaATION FEE TOTAL FE j /L,,.�Z .,I
SEE REVERSE FOR EXPLANATORY LANGUAGE ,