HomeMy Public PortalAbout5516TEMPLE CITY BLVD_Building (2) WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of cement a self , APPLICATION FOR BUILDING PERMIT ,IIUIII
insure, or a certificate of Workers s Compenaatlon Insurance, ,
or o certified copy thereof (Sec 3BDD, Lab C ) ._ - COUNTY OF LOS ANGELES 'BUILDING AND SAFETY '
Policy No Company '
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy Is filed with the county building Inspec- BUILDING
hon department ADDRESS
Date-'Applicant CITY i/� / ZIP ( / LOCALITY '
pD NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF 103� .. 6.5 plow ON LOT _ cRo55 S7
tI -COMPENSATION INSURANCE - _ ASSESSOR -
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO ' MAP BOOK -- - PAGE , PARCEL
hundred dollen ($I00)or less )
r OWNER O NO p ZONE MAP
�,I certify that in the performance of the work for which this
SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS./ ✓ / �/y 7� iC /- L IND CONDITIONS
a
so as to become subject to the Workers' Compensation laws
CITY 'All
Date Applicant ARCHI OR TEL
NOTICE TO APPLICANT If, after making this Certificate of - ENGINEER NO DISTRICT GROUP TYPE "' FIRE PROCESSED BY O
Exemption, you should become subject to the Workerp ,y CONST Z E
.Compensation provisions of the Labor Code you must forth- _ ADDRESS - - -- •of
with comply with wch provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT I CONDO in
deemed revoked CONTRACTOR Lt NO . z
r , LICENSED CONTRACTORS DECLARATION LIC CLASS NO 1411 DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO '
(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP
and Professions CITY A Code,and my license is in full form and effect BK PG VALIDATION
SO FT NO pF NO FAMOF CCHECKLicense Number Lic Class SIZE STORIES IUES ONE
VALUATION
Contractor Date- DESCRIPTION OF WORK / NEW 0S O G v r -
❑I am exempt under Sec C D �� G a�- ADD ❑ ►
/' p /� ALTER ❑
B 8P C for this reason A^" J T``f /- !/ EPAIR ❑ s
Date USE OF
BUSTING BLDG DFMOL ❑
Signature APPLICANT TEL - FINAL
OWNER-BUILDER DECLARATION (PRINT) NO DATE L _
I hereby affirm that I am exempt from the Contractor's License ADDRESS `
Law for the following reason (Section 7031 5, Business and FINAL '
Prof Code) . _ _ By 3307 98.63
I, as owner of the property, a BUILDING
my employees with ADDRESS - 1 ITM
s as
wagetheir sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY , TOTAL y 98_63
7044, Business and Professions Code ) MOVING
- ' TEL
1 1rFTGbf� 98.63
❑ I as owner of the property,am exclusively contracting
with licensed contractor to construct the project (Sec- ADDRESS - .011tion 7044, Business,and Professions Code ) _
CONSTRUCTION LENDING AGENCY I RED YARD HWY TOTAL SETBAIX FROMEXISTr - "
I hereby affirm that there iso construction lending agency for F T E WIDTH
000001 - 11/17/92
the performance of the work for which this permit is Issued PL
(Sec 3097 Civ C ) SIDE
PL - - - 6553 1 AM :t9
Lender's Name -
-
Permit Fee LDMA Ref N --
P C Fea f
Lendels Address - _ +
o I certify that I have'read this application and state that the Issuance Fee / + LDMA P/C N pop
above information is correct I agree to comply with all County InveAtpanon Fee _
ordinances and State-lows relating to budding construction, Total Fee Op/ to J LDMA Perm •
and hereby outhonz r presentativm of this County to enter
upon-tbe.ebove- ed property for inspection purposes
2 _ _ WE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant m Agent Data I