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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 - _ - - - +