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
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