HomeMy Public PortalAbout5728 A-ETEMPLE CITY BLVD_Building f' WORKERS COMPENSATION DECLARATION I
thereby a cafltat b certificate of consent to self
r , APPLICATION FOR BUILDING PERMIT ILJI
Insure gr a tatrf¢ off r son
ote of Workers Compenon Insurance
or a cerhfibk
d copy theaf (Sec 13800 Lab .0)
COUNTY OF l05 ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy Is hereby furnished FOR APPLICANT TO FILL IN BUILDINGADDRESS
Certified copy is filed with the county building mspec BUILDING �s a
tion department ADDRESS � -s—5 / a6 -r"•'LF LE DLV
Date Appl scant CITY C T ZIP LOCAL ITV
CERTIFICATE OF EXEMPTION FROM WORKERS 18 S05 SF NOW ONBIDGS
LOT IJFARES
SIZE OF LOT ST
COMPENSATION INSURANCEASSESSOR
l
(This section need not be completed If the permit Is for one TRACT 65 6 BLOCK LOT NO 6o MAP BOOK PAGE Pq L
hundred dollars($100)or less ) _
I certify that in the performance of the work for which this OWNER u ,1^O O TEL
2 USE E MA P 3T L'. 146
permit is issued 1 shall not employ any person In any manner ADDRESS 5 W i SaFSfih S SPECIAL
so as to become subject to the Workers Compensation Lows /n� CONDITIONS
Dote Applicant CITY Cha r4en Q- ZIP q0 a.;
NOTICE TO APPLICANT If after making this Certificate of ARCHtTER OR
(( IL e-/II t�j Lp V DISTRICT GROUP TYPE FIRE SSED BY 0
Exemption you should become subject to the Worker ['� //�� CONST / ZONE
Compensation provisions of the Labor Code you must forth ADDRESS i 1 VQ J 4 *IQr K 1 / �i
with comply with such provisions or this perms shall be V
deemed revoked CONTRACTOR NO STATISTICAL CIAS/S�jIF(1CJp�7(pN APT NDO Z
LICENSED CONTRACTORS DECLARATION y,, /�_ J CLASS NO 04/#DWEU UNITS_
I hereby affirm that I am licensed under provisions of Chaptertil ADDRESS 1✓ De LI e-terIN14'IL
(commencing with Section 7000)of Division 3 of the B nm and LIC SEWER MAF
Professions Code, and my license Is In full force and effect CITY CLASS BK ' PG VALIDATION
SO FT NO O NO OF CHECK
License Number Lsc ClassSIZE 6 STORIES FAMILIES OPE
vALUA N -9 0 2 1.9 A
Contractor Dote DESCRIPTION OF WORK NEW
A�G, ADD # • • • 0 2 3
I am exempt under Sec -LIMIT MC-F1 ALTER
B 8P C for this reason REPAIR $ i - 52613
Date USE OF -
DEMOL L� O e e 5 2 61 3 6
.LISTING BLDG
Signature APPLICANTTEL Si$ �' FINAL �/ Q 0 7 1 8—8 8
OWNER BUILDER DECLARATION PRINT Q f F,y.,-I L 1 a DATE
I hereby affirm that I am exempt from the Contractor a LicenseG$
Law for the following reason (Section 7031 5 Business and ADDRESS tit
Professions Code) By lT li"�'•_ �'
OI os owner of the property or my employees with BUILDING
woges as their sole compensation,will do the work and LOCALITY
structure Is not Intended or offered for sole(Section
704 Business and Professions Code) MOVING TEL
I, m owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS
non 70" Business and Professions Code)
CONSTRUCTION LENDING AGENCY REQUIRED Albi
SET BACK YARD HWY pgOp IINE WIDTH
I hereby affirm that there Is a construction lending agency for FRONT l
the performance of the work for which this permit is Issued P L - y
(Sec 3097 Civ C ) SIDE
PL
Lenders Name
$ Jf / LDMA Ref Y
Lender a Address P C Fee f ^ F Perms Fee t '
/
I certify that I have read this application and state that the 7 Iswonce Fee J 21 LDASA.P/C R a3n
above Information Is conect I agree to comply with all County In."g000n Fee
8 ordinances and State jaws relating to building construction Total Fee / L LDMA Perm Y
R and hereby authorize representatives of this County to enter
upon the above mentioned property for Inapecllon purposes
S M RFVUW FOR tXrLANATORY I AN"AGe I'
Sgrwtur of Applicant or Agent Dote I U '