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HomeMy Public PortalAbout5728 A-ETEMPLE CITY BLVD_Building (2) WORKERS COMPENSATION DECLARATION a+l he-eboo cemthatel have certificate of consent r self APPLICATION FOR BUILDING PERMIT mute or a certificate of Workers Compensation Insurance or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF l05 ANGELES BUILDING AND SAFETY Policy No Company BUILDING Certified copy s hereby fumeshed FOR APPLICANT TO FILL IN ADDRESS g7� Certified copy is filed with the county building mspec BUILDING �l tion department ADDRESS tJ / t 4 -t., Dote Applicant CITY s- ZIP NEAREST COMPENSATION LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS yg OF l07 X �,SD,,• dNO' ON T 1-. NEARS ST COMPENSATION INSURANCE L (This section need not be completed If the permit Is for one TRACT 6 ? BLOCK LOT NO ASSESSOR hundred dollars ($IDD)or lea ) - MAP BOOK PAGE PARCEL 5E E I certify that in the performance of the work for which this OWNER permit Is Issued, I shall not employ any person in any manner ADDRESS 1Sk14 S COFDITION to as to become subject to the Workers Compensation La p Date ! —b` �a ,spPII r t CITY ���..V ZIP D.�- USF NOTICE TO APPLICANT If ah king this Certificate of ARCHITECT OR TEL DISTRICT TYPE FIRE 0 Exemption you should subject to the Workers' ENGINEER NO �T/\ // CO!'15T/ Z NE U Compensation provestons of the Labor Code, you must forth- ADDRESS (J K �/ with comply with such provision or this permit shall he deemed revoked STATISTICAL CLASSIFICATION APT DO 4) CONTRACTOR Z LICENSED CONTRACTORS DECLARATION UC CA 55 NO ?' DWELL UNITS I hereby affirm that I am licensed under provisions of Chopter 9 ADDRESS NO (commencenp with Section 7000)of Division 3 of the Business and LIC Professions Code, and my license is in full force and effect Cm CLASS i VALIDATION SO FT NO OF NO OF CHECK License Number Lec ClassSIZE STORIES IFAMJUES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ADD E Cl El1 am exempt under Sec ALTER B 8P C for this reason REPAIR S USE OF ;2009,1 A DateEXISTING 8LDG OfA10L Signature APPLICANT TEL FINAL Qp # • • •I• •!1 OWNER-BUILDER DECLARATION PaINr NO DATE =3 0 ,) •,• 6 0 5 0 I hereby affirm that I am eiempt from the Contractor's License Law for the following reason (Section 7031 5 Business and ADDRESS RNAL Professions Code) BT 24�. ' • ' 6 0 5 0 5 El BUILDING I as owner of the property w my employees with ADDRESS 0706-88 wages as their sole compensation,will do the work and LOCALITY the structure is not Intended or offered for sale(Section 7040, Business and Professions Code) CMOVING TEL Poo. ONTRACTOR NO I or;owner of the property am exclusively contracting with licensed contractors to construct the project (Sec ADDRESS tion 7040 Business and Professeom Code) CONSTRUCTION LENDING AGENCY PUAM YARD HWY TOBACK FROM EXIST TAL LIE WIDTH I hereby affirm that there so construction lending agency for FRONT the performance of the work for which this permit is issued P L (Sec 3047, Civ C ) SIDE PL Larder s Name LDMA Ref e SydV $ Larder s Address P C Fee f Perms fee J)//�� I certify that I have read this application and state that the Wuarice Fee 6(/� LDAAA P/C• pop above enformoltori is correct I agree to comply with oil County Invesuguem Fee 8 ordinances and Sate laws relating to building construction, Total Pee a' LDMA perm Y R and hereby authorize representatives of this County to enter upon the above-mentioned pr party for inspection purposes ^ 2— 6 _ o—rT f@ 6V131E FOR[KRAMATWY IANOU C�F aM•of Applicant or Agent Dan ^n, _& s /I U 1 �/'7 Y-