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HomeMy Public PortalAbout5722 A-ETEMPLE CITY BLVD_Building (2) WORKERS COMPENSATION DECLARATION `- I hereby a ,hat have a <erte of consent a self � APPLICATION FOR BUILDING PERMIT �TltLbcer Comm re or a certificate of Workers Compensatn Insurance or o certified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company BIIkONG F1 Certified copy a hereby furnished FOR APPLICANT TO FILL IN S� eA ADDRESS 13 Candied copy a fled with the county building mnpec B DING / iv tion department SS .707 P Dote Applicant 1 -' Ci ZIP A LOCALITY r CERTIFICATE OF EXEMPTION FROM WORKERS OF LOT )' "Ar ,OF BIDGS 1 NEAREST COMPENSATION INSURANCE _ ON L 5T (This section need not be completed if the permit a for one t ASSESSOR hundred dollars ($100)or less ) TRACT 6Stl BLOCK` �. LOT NO MAP BOO( PAGE PARCEL <<. . TEL / USE ONE L �r� 1 certify that in the performance of the work for which this R �� Ns0 NO permit is issued, I shall not employ any person in any manner s-a j-� -� SPECIAL , so as to become subject to the Worker Compensation Laws ,,,1 CONDITIONS Dale D`�8 Appllca s .��/� C/�• ZIP �eZ (( K NOTICE TO APPLICANT If a ung this Certificate of Jh*ARCHITECT DISTRICT GROUP TYPE FRE PROCESSED BY O Exemption you should subject to the Workers INFER ,S (aNST I �rTUE U Compensation provisions of the Labor Code you must forth ADDRESS i K V 3 with coripty with such provisions or this permit shall be deemed revokedSTATISTICAL C1A551FICATION APT DO N CONTRACTORZ LICENSED CONTRACTORS DECLARATION I I VJ UC CUSS NO DWEI I UNITS_ t hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS A NIO (commenting with Section 7000)of Division 3 of the Business and I LIC SEWER MAP Professions Code, and my license is in full force and effect CITY CLASS BK PG _ VALIDATION SO FT NO OF NO OF CHECK License Number Lic Class SIZE STORES FAMILIES ONE )b 1 VALUATION Contractor Dote DESCRIPTION OF WORK NEW $ , ADD 30,09, OA I am exempt under Sec A ALTER # B 8P C for this reason REPAIR : USE OF 1 • • 6Q50 Date EXISTING BLDG DEA10L Signature APPLICANT TEL FINAL . • • 6 Q 5 0 5 OWNER BUILDER DECLARATION PRINT NO DATE Z 1 hereby affirm that I am exempt from the Contractors License 0 06788 Law for the following reason,(Section 7031 5 Business and ADDRESS Professions Code) BY 4",j 1 as owner of the prop , or my employees with BUS erty wages ns their sole compensation,will do the work and LOCALIIv the structure is not Intended or offered for sale(Section 7044, Business and Professions Code) MOVING TEL I as owner of the property, am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code) ADDRESS ` CONSTRUCTION LENDING AGENCY RECILILRED SET BACK YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P L (Sec 3097 Cry C ) SIDE PL Lender s Name D 8TDMA Ref 1 Lender s Address P C Fee f Permit Fee 9 1 comfy that I have rood this application and state that the Issuance Fee D LAMA P/C• 9 above information is correct 1 ogres to comply with all CountyIn.angotronee F ordinances and Sate lows relating to building construction Tocol Fee p (/t LDMA Perm f and hereby authorize representatives of this County to enter upon the above-mentioned rope for inspection purposes Cf-02 .75 U2 ',7S NA Y /uLl a of Applcmn a Agem f@ OV9i!FOR E%/LAO[Y s� �IiISL 2 2 7 5 lvd—