HomeMy Public PortalAbout5454TEMPLE CITY BLVD_Building ' Iy.,VORKERS COMPENSATIdN DECLARATION
Thereby affirm that I hf Workers
certificate ns consent to self _APPLICATION ,FOR BUILDING PERMIT
• insure, w a certificate of Worker Compertaotion Insurance, --
wr a certified copy thereof (Sec 3800 Lab C ) _ COUNTY OF LOS ANGELES - - +
BUILDING AND SAFETY_
Policy No Company
BUILDING / - ,
❑ Certified copy is hereby furnished FOR APPLICANT TO FIL91NADDRESS PIE❑ Certified copy Is filed with the county budding inspec- ARES646 - - - -
tion department
C/T► _Date Applicant CITY ZIPLOCAUTVCERTIFICATE OF EXFJJiPTION FROM WORKER$' SIZE aF LOT x NIrnV ON LOCROSSSS7COMPENSATION INSURANCE ASSESSOR(This section need not be completed if the permit is far one TRACT BLOCK LMAPBOOK - PAGE -- PARCEL -—
'hundred dollars ($100) or leu ) r OWNER NO 26 .'q, USE ON MAP
I certify that in the performance of the work for which this
permit a issued I shall not employ any person in any manner ADDRESS C SPECIAL- - 1 z }a
coNDmoNs
so as to om subject to the Wog, Co penso laws 0
CITY ZIP
Date Applicant ARCHITECT OR TEL DISTRICF I GROUP I TYPE FIRE D BY O
-NOTICE!TO APPLICANT If, a r eking this Certificate of ENGINEER NO CONST ZEE
Exemption, ,you should become sublect to the Workers •V
Compensation provisions of the Labor Code, you must forth- ADDRESS t
og with comply with such,provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO
Z
deemed revoked CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION UC CLASS No DWELL uNrrs_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO -
(commencing with Section 7ODD)of Division 3 of the Business LIC SEWER MAP ^
and fkofensions Code and my license is infull forceand effect CITY U CLASS PIG N� VALIDATION
SO FT NO % NO OF CHECK
License Number •Lic Class - SIZE STOR FAMILIES ONCE r
VALUATION
Contractor Dote DESCRIPTION OF WORK NEW •❑
❑I am exempt under Sec ADD ❑ loop '
ALTER [0
B BP C for this reason
Date 115E OF
EXISTING BLDG DEMO- -
L
r Signature APPLICANT TEL NO FINAL
OWNER-BUILDER DECLARATION PRINT) DATE I Z
1 hereby affirm that I am exempt from the Contractor s License _ _ _
Law for the following reason (Section 7031 5, Business and ADDRESS FINA 3307 60.50
Prpfesstant Code) PRESENTBUDB _
}WPI 1, as owner of the property, or my employees with ADDR� 1 I
wagesas their sole compensation will do the work and LOCALITY - - - , _ - - i TOTAL 60 .50
the structure is not intended or offered for sole(Section
7044, Business and Professions Code MOVING _ , TEL _ �s�/y /Lf�Js
❑ I as owner of the property, am exdunively contracting
CONTRACTOR NO - MCK 60.50
with licensed contractors to construct the project (Sec- ADDRESS - - - - r - .00
tion 7044, Business and Professions Code )
CONSTRUCTION LENDING AGENCY I D YARD �Vy 7Al SETBA,i](FROM
I hereby affirm that there is a construction lending agency for FRONT F I i O 1 8/25/89
the performonce of the work for which this permit is issued P L - — -
(Sec 3097, Civ C) SIDE 5316 1 ` AMIDOO
PL
y Lender's NameLIMA Ref
^ - PC Fee S Permit Fee OD S
Lender's Address ► r
I certify that I have read this application and state that the Issuance Fee z�0 LDMA P/C 0
above mforntotion is correct I agree to comply with all County Invesngotron Fee
ordinances and State laws relating to budding construction Total Fee s LDMA Perm R
and hereby authorize repres ntotivet of this County to enter
upo abov est n perry for inspects n
-4 !! - WE REVERSE FOR EXPLANATORY LANGUAGE ,
igoature of Applicant or Agent Dai