HomeMy Public PortalAbout5466TEMPLE CITY BLVD_Building (2) all APPLICATION FOR BUILDING; PERMIT
COUNTY OF LOS ARGECES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPUCANT TO FILL IN S R mss
I hereby affum that I have a certificate Of consent to Bell insure
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or e cefafcete of VworkersCompersatior Irsurarce or e certrhed / ,
copy therad(Sac 3800 Lab C) LP
Policy /
LOt
CALRY
S OF NO OF S NOW ON LOT
417
dedm hereby ma
NEAREST CROSS ST
❑ Certified copy IS filed with the c bwdl i cn TRACT BLOCK LOT NO
'Ldru.um ant USE NNE AVP NO
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DateeJ��" ApPkal't ASSESSOR MAP BOOK PAGE PARCEL _
SPECIAL CONDITIONS
CERTIFICATE OF EXEM O OM WORKERS' R TEL
COMPENSAM N NCE , VynHIN 1000 FT OF SCHOOL' YES NX1
(This section reed not be d the permit s for one hundred WARCHMECT
L
DISTRICT GROUP TYPE CONST FIRE NNE PROCESSED BY
dollars($100)a law)
I certify that m the performance of the work for which the permit
6 Issued I shall not employ any person In arty manner oro Y to E EER TEL NO -
beConle subjeof to the Workers Conpenlsatcn Laws SWTISRCAL CLS�TION , ART
CONDO
Date i Applicant ADDRESS . CLASS NO C.A / DIELL '
N077CE 70 APPLICANT If after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemlpho l you should become subject to the Vkxkens CONTRACTOR TEL SET BACK YARD NN.'Y PROP UNE YADTH
Compersaton prowsona of the Labor Code you must forthwith
FROM
comply vnth ouch provscrs or the permit shall be deemed revoked AD LIC NOP L }
rle
LICENSED CONTRACTORS DECLARATION P - a
SIDE
Le C PL 0
1 hereby affirm that I am Warmed underprovsons of Chapter BU
(COmlmlencmp with Section 7000)of Division 3 of the Busmess ant s0 FT 9ZE_ OF TORIES NO OF FAMIUEs NEW ❑ R MAP BK P3 O
Professions Code and my license s In full lace and effect o
L iceree Number Lc Class, J TqN OF VAHK,//`�' ADD ❑ W&UARONUl
Contractor Data ;�,c�,,lq/ - /L / 1 ALTER ❑ $ O-
❑ 1 am exempt under Sec S REPAIR $ Z
BAPC for this reason pnp 4�6 Y A' MOL ❑ LOW P/C. _
to F IsnND SLDOON A7�c�/µ�Qacp/� URM ❑ 1
❑ I esreowner 01 the ty rry employees wl�th wages as
fir r'W /V 066 LSA gym, ACCT.T
their sole cos t writ m the work and the structures ...yam /f 3303 158.85
not Intended df fa Bale (Sector 7044 BU91ness and FINAL DATE 1 TTL-ML+
Professions N1LL THE APPJCANi OR FUIUiE Bl1LLY+o CCC1PArri HAMCIE HAZA{o(X/s MATERL O 1 GI{J
❑ I ore owner of the property am exclusively contracting with ORA MI%T1XE CONnN A HAZAR(K)1ra I.MTERPI.EOLLLL TdOR OFEATER TNAN THE FlNAL TOTAL 159 _ u
loemsed contractors, to corntruct the project (Sector 7044 YES 1:1 �o1� THE MATERML9 PFORNATioN alpE+
Busi and Professore Com) YES❑ TE❑ CHEM Y. 158.85
OCCUPANT
CC THE INTENDED USE OF THE CONSTo BY THE WCOIFCA OR FU T eUROPo CHARGE .00
CCW WAR REOUFE A FEREIi NT 5rN UCTA01 OR MOORIGioN FnCW THE r FOR
CONSTRUCTION LENDING AGENCY COAST AP OIMIITY NWMpE1ENi(XSnF�i 15UOM01 SEE PERA1mTNp CHECKLIST FOR
tN10E1JNEs _
I hereby affirm that there Is a constructor landing agency for YEy❑ ❑
the performance of the wo for which this permd Is,memed(sac 0-0001 5/ 2/96
3007 CN C) IIUYE FEAR nE HAZARpa19 MATEBALsnswwnoNouOE ANO TIE scAcuo FEFernwp
OECkt-19T I UNOERSTNO M1'REpUpEn.ENTa UN ER THE LOS ANOELE900 2 20 140 00NCEFNING NrY CODE
Lender 9 Name IATITLE wA1PwCWTER iiq IMvcp FORS 3 20 100 pHPNIq Ai�PEPo,IR FROA ""�"'�°"a 176 1 AM 11 25
Landera Address -r
MKN CR.YI[tt
I certify that I have read the applcabon and state under penalty PC FEE PERMIT FEE -
of partury that the above information s correct I agree to compty
With all county ordmances and State lawn Ieletag to buildup JJ .
0DOOMWn and hereby nze representatives Of the County ISSUANCE FEE
pp= to mthe abov - en red propertyfo Ian rposee s,7 30 '
Y c,. INVESTIGATION FEE TOTAL FEE
iG ,o.u. Aum„ I
BEE REVERSE FOR EXPLANATORY LANGUAGE