HomeMy Public PortalAbout5479TEMPLE CITY BLVD_Building (2) APPLICATION FOR BUILDING PERMIT_
COUNTY OF LOS ANG BUILDING AND SAFETY
• WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN &IILDIN3 ASS
I hereby affirm that 1 have a cerrtitcate of consent to self insure BUILDING ADDRESS n -
or a certificate of Workers Compensation Insurance or a certified
Copy thereof (Sec 3800 Lab C) OTY qr. `117
P 1I go
LOCArPolicy No Compary, SIZE/OF 1, NO OF ON LOT
13Certnfod copy is hereby hlrnnotled 14 h Q NEAREST CROSS ST
❑ Certified copy is filed with the county Wilding inspection BLOCK LOT NO '
department __ __ _ _ _ - _ USE ZONE - _ MAP NO
Date Applicant ASSESSOR MAP BOOK RAGE PARCEL
- � 3F'EGIPl CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' 0 TEL NO
COMPENSATION INSURANCE VF ✓AIVA67 51 NOR WITHIN 1000 FT OF SCHOOL' YES NO
(Thee
AGGRESS dSTRICT GROW TYPE CONST FIRE ZONESSEO BY
s ($section need not W wnpleted it the permit s
dollars(5for one hundred71y 5� C STS ��
100) a less)
I certify that in the performance of the work for whioh'this permit CITYKil T 'CA-
s issued ny,I shall not employ any person In amanner so as to N ��� -�
become Subject to the Workers Compensation Laws ARCHITECT OR ENGINEER TEL NO
SV1nsn1 CLAS.SIfGATION PPT CONDO
Date Applicant ADDRESS _ CLASS NO DWELL UNITS
NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you should become Subject to the Workers CONTRACTOR TEL NO SET BACK vAAD HWY PROP UNE WIDTH
Compensation provisions of the Labor Code you must forthwith
conpty with Such provisions or this permit shall be deemed revoked FRONT
ADDRESS LIC NO P L
LICENSED CONTRACTORS DECLARATIONODE
CRY LIC CLASS P L
I hereby affirm that I am licensed underprovBons of Chapter B
SEWER MAP
(commencing with Section 7000)of Dwision 3 of the Business and SO NO OF STORIES NO OFAM¢lES
Professions Code and my license s in full force and effect NEW BK PG oil. d
License Number LlC] VA
c Claes IPTION F RK ADD LUATION Q
Contracts Datan �-- p ALTER ❑ $ 4
❑ 1 am exempt under Sec �7 STM EPAIR ❑ $ I
B&PC for this reason DEMOL ❑ LDPIC♦ .. W
Date F EXISONG B URM ❑ MA - i d
Signature APf1CANT(gayT) TE NO LDMA Perm♦ 1 Z
>{I as owner of the property or Try employees with wages as AIV V9 z A[C[.r
their sola compensatcn will do the Mark and the structure is SSF -.7 — �r -c
not Intended or offered for sale (Section 7044 Busmess and RNAL DATE •'-
Professions Code) VA1 TIE APPDC/Jri pq flfnlRE OCCI1Mlrt HIf10.E A WTERUL „�
❑ 1 as owner of the property am exclusrvey contracting with OR"A° poN m " a"T�""L eou.L ro TIUR TIE 1 >_TE�S
91 0
Icersad contractors to corstruct the project (Section 7044 "r'�'FD�SPECIFIED off TIE 1u 00us euTwirLs NFGPoM GUIDE? FINAL JT 11 1 AL 89 � 25
Business and Protesslors Code) YES❑ ^X _r 14, lC
WILL THE NTaenED UM OF TIE euu BY TIE APPUCINi OR RTUE BUILDmp .HErK Am -
sr T�waDuirRv AiwwL I.�Ei°mDa RIOT r(vo1 SEE rxECKKUST F901OR l
CONSTRUCTION LENDING AGENCY c GLOEUWS CNgf�7E =I-I
I hereby affirm that there is a construction lending agency for YEa❑ -/9 _
a the performance of the Mork for which this permit s sued(Sec q
m 3087 CryC) CHEa�l9 11tioETfE NAp rAEr°fl6i.N0Eri TSF 1D uiOELE scou�Nry CODE I Q[I[IJ—[1[1(11 17.�,.J"94
11nE T Z 10p T .,.]to 1r0 LONCEPldlq NAZ Rccus
Lenders Name MAtE�PJrrn AF aFTlpAr TIE 9V9ND -- C
Lenders Address
0 owrn or.
o I certify that I have read this application and state under penalty
of perjury that the above mformaton is correct I agree to campy PC FEE PERMIT FEE l
$
With all county ordinances and State laws relating to Nuking d
CorstrIon end hereby authorize presentatwes of this Couny ISSUANCE FEE
m toe orl the -nsmio perty la
✓ �9 INVESTIGAT10N FEE TOTAL FEE �1
m Oa
some d"ager o�
SEE REVERSE FOR EXPLANATORY LANGUAGE