HomeMy Public PortalAbout5466TEMPLE CITY BLVD_Building WORKERS COMPENSATION DECLARATION ^
sre, o affirm that have a certificate of cion Insurance,
self
insure, FOR BUILDING PERMIT ,CI'lll,
suraor a certificate of Workers Compensation -
or a certified copy the/-eogf (Sec 3800, Lob C�)� c. r ,COUNTY OF LOS ANGELES -- _ BUILDING AND SAFETY
Policy No! 3�7ompany S�/�_J V'V d BUILDING C: -
® Certfled copy is hereby furnished' FOR APPLICANT TO FILL IN - " ADOR65 �J �Q (/�r
-❑
Certified copy dfiled with the county building inspec- BUILDING - _
tion department ADDRESS
Date 1_ � Applicant CITY/9- 9 � C ( 7• O ZIP LOCAUTY '
` CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON O 5 - NEARESTCOSS
COMPENSATION INSURANCE r ASSES 5T -
(This section need not be completed if the permit is for one TRACT - BLOCK - LOT NO - R o Dp
hundred dollars ($100) or less ) TEL MAP BOOK p`�a 6 PAGE02_3 PAR(EL02Z
OWFER V NO�-e 7' C)O USE ZONE' MAP
I certify that to the performanceiof the work for which this _ _
permit is issued I shall not employ any person in any manner ADDRESS r0 r CC L�. " ItEONS
TIONS ' a
so as to become sublect,to the Workers Compensation Lawsp O
' - CfTY ZIP 7 O o -, - U
Date Applicant ARCHITECT OR TELDISTRICT G P TYPE FIRE BY Qc
ExempNOTICt TO APPLICANToIf, after Making subjec this the Certificate of ENGINEER NO �ro'/ (,TTTT 1 ZpNE 0
Exemption, you should become subject i the ,ficate f 9yy K c�� 3 tV
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provision or this permit shall be TEL 7 STATISTICAL CLASSIFICATION DO Z
deemed revoked z CONTRACTOR !C NO l -03
LICENSED CONTRACTORS DECLARATION pp LIC CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 'ADDRESS 6� S✓N�uf NO 4' SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC
and Professions Code,and my license o m full force nd effect CITY U CLASS SK PG VALIDATION
FT NO OFNO OF CHECK i
License Number.YT�YUc Class SIZE STORIES FAMILIES ONE
Contractor&C1C hc .trr;/V VALUATION
Date DESCRIPTION OF WOE( V NEW ❑ S _
❑
ADT
1 am exempt under Sec ❑ ,
_ ALTER ❑ -
B 8P C for this reason '
I REPAIR L�JI/ -$
115E OF
—Date - EXISTING BLDG DEMOL-.C� +
_ Signature APPLICANT TEL ANAL
OWNER-BUILDER DECLARATION MMI NO DATE I
r I hereby offirm that I am exempt from the Contractors License ADDRESS _
Low for the following reason (Section 7031 5, Business and FINA 1
Professions Code) PRESENT • - u _ By
_
BUILDING
❑ 1, as owner of the property, or my employees with ADDRESS — _ - GT•*
wages as their sole compensation,will do the work and
- - t
the structure is not intended or offered for sale(Section LOCALITY I , _ — - 3307 88.00
7044, Business and Professions Code ) - MOVINCONTRAG TEL NO 1_ - 1 I IU1.
El 1, as owner of the o - - +
pr party, am exclusively contracting
with licensed contractors to construct the project (Sec- - - ADDRESS - - ' -) TOTAL. 88 . 00
eon 7044, Business and Profession Code ) V
T CONSTRUCTION LENDING AGENCY - YARD �, Al CK FROM I57 u r ' (�(K 83.00
1 hereby affirm that there is a construction lending agency for FRONT l
wImH
the performance of the work for which this permit is Issued P L - - - AH� .00
(Sec 3097 Civ C ) - SIDE -
- PL
Lender's Name
PC Fees Pit a , t LDMA
ermRef F LIVW'LR7V1, 1�18�9CI
Lender's AddressPilo8342 1 A M 8:42
o I certify that I have read this application and state that the Issuance F 3 , 00 LDMA P/C 0 -
above Information is correct I agree to comply with all County Invesegaeon Fee i
ordinances and State laws relating to building construction, Totol tae ,TDMA Perm.d
and hereby authorize representatives of this County to enter -
^ u n the a o tied property for Inspection purposes I
� SEE REVERSE FOR EXPLANATORY LANGUAGE
r
+ Signoture of Applicant or Agent Data - _ - - - +