HomeMy Public PortalAbout5454TEMPLE CITY BLVD_Building (2) A !,WORKERS COMrLNSATIOIIJ DECLARATION
hereby affirm that I have a certificate of consent to self - 'APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Worker Compersotion Insurance,
or a certified copy thereof (Sec 3800, Lab C ) - COUNTY OF LOS ANGELES •- - - BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IqNOA&AOkP
5 Q Lv�
❑ Certified copy is filed with the county building inspec- BA IDDRESSs 545 MAE - I
hon department
Dare Applicant CITY F ZIPLITY131�1 r
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT SI ZZ r NOW ONNO OF&OqqNEAREST Q�wA
COMPENSATION INSURANCE SS ST
(This section need not be completed d the permit is for one TRACT BLOCK LOT SSOR
hundred dollars ($100)or less ) l TEL BOOK PAGE PARCEL' OWNERMII . NO NE MAPI certify that in the performance of the work for which thispermit is issued, I shall not employ any person in any manner ADDRESS 4 p CONDISPECIAL dso as to become subject to th Wor 'Co penaati Laws CONDITIONS O
CITY -r T ZIP Date Applicant ARCHITECT OR TEL d'NOTIC TO A PLICANT If aft r akmg this Certificate of ENGINEER I /_ GnROUP ryONST �IORBJE BY O
Exemption, you should become subject to the Workers �y /��Compensationprovisions of the Labor Code, you must forth- ADDRESS (J I
with comply with such provisions or this Permit shall be TL STATISTICAL CLASSIFICATION APT CONDO 14,
Z
LICENSED deemed roDECLARATIOvoked CONTRACTORCTRACTOR NO CLASS NO DWELL UNffS
- SED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapteri? ADDRESS NO
(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP
and Professions Code,and my license is in full force and effect CITY CLASS BK D PG �,p' C VAUDATION
SO FT NO NO OF ' CHECK
License Number Lic Class SIZE RIES FAMILIES ONE
VALUATION
Contractor Dote DESCRIPTION OF WORK NEW ,OQ '
❑1 am exempt under Sec ADD ❑ f `,/`�/ ,
i
r YALTER ❑❑ $ - - -
B 8P C for this reason K.7 — ` REPAI
Date USE OF _ -
DUSTING BLDG DFMOL ,
Signature APPLICANT TFL FINAL
OWNER-BUILDER DECLARATION -
DATE
I hereby affirm
NO
m that I am exempt from the Contractor a License - ADDRESS '
fill
Law for the following reason (Section 7031 5, Business and FINAL _ 1
Professions Code) _ By _
® I as owner of the property, or my employees with ADDRESSBUILDING - - ACCT.* - I
woges as their sole compensation,will do the work and 115'50
LOCALITY
the structure is not intended or offered for sale(Section , '. ,
7041, Business and Professions Code ) MOVING TEL 1 ITEM;
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO
- - TOTAL 115.50
with licensed contractors to construct the project (Sac-
ADDRESS
hon 7044, Business arta Professions Code ) -
CONSTRUCTION LENDING AGENCY SET ICED YARD tLsvV ALPRVLFROM '' ' (NICK 115.50
I hereby affum that there is a construction lending agency for FRONT - 7 - .00
the performance of the work for which this permit is issued P L - - - —
(Sec 3097, Civ C ) SIDE
PL
Lender's Name -� ,L t.001 8/73/89
5. D LDMA Rel « ' 5317 1 AM11:00
P C Fee S Permit Fu
Lender a Address //!!�� - 01111. - - -
I certify that I have read this application and state that the I.auunce Fee - 0 N 5 L)MA P/C Y
above information is correct I agree to comply with all County Inveerigotion Fee
ordinances and State jaws relating to budding construction Total Fee 5, 501CDMA Perm !
` and herebyauthorize representatives of this County to enter
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8Yq bomenho Property for iropec7io� ^
Ali" fEl 16VEOl FOR EXPLANATORY UMOUAO!
Signoture of Applicant or Agent e