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-