HomeMy Public PortalAbout5743TEMPLE CITY BLVD_Building WORKERS' COMPENSATION DECLARATION I
insure bohereraa certificate of Workers' Compensat on Insurance, '/7PP L I CAT I O N F®m-. RM I
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES (• BUILDING AND SAFETY '
Policy No. 9(16611at1Company BUILDING �y � /fJ )l� + C.
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSZ11 /, TC
i JEBUILDING
Certified copy is filed with the county building inspec- ADDRESS 1 �.; +T tion department.Date 1�.�1-.RQ• Applicant_ R.nrld' lXRnn' �a ITY �eG'y: ZIP. LOCALITY•NO.OF BLDGS: NEARESTCERTIFICATE OF EXEMPTION FROM WORKERS' ' IZE OF LOT NOW ON LOT :CROSS ST.
COMPENSATION INSURANCE
ASSESSOR
(This section'need not be.complefed if the permit is for one TRACT BLOCK LOT.NO. MAP BOOK PAGE PARCEL
hundred dollars ($100).or less.) TEL. USE ZONE MAP
OWNER George; Pc3t�4C NO.443-4917 . NO.
I certify that in the performance of the-work for which this. SPECIAL }
permit is issued, I shall not employ any person in any manner `ADDRESS. 10106 Lindgeer CONDITIONS'
CL
so as to become.subject:to the Workers'Compensatidfr1aws. .. CITY
" • �eL+ye ZIP �17$G C
10-2G-99. Rkandol •Roofing. C
Date Applicant. ARCHITECT OR TEL.: DISTRICT R IJR� TYPE FIRE 1�ROCESSED BY LL
NOTICE TO APPLICANT: If, after making'this Certificate of '• a ENGINEER', NO.. CON z
'Exemption, you should become subject to the VI)orkers' t' u
Compensation provisions of the.Labor Code, you'musi forth- ADDRESS �, '.l I\ _/ R }
' .. with comply'with such'provisions or this ermit, shall be TEL. ` O
. P P h $TATISTICAL CLASSIFICATION APT! CONDO. G
deemed revoked.; CONTRACTOR 4 'NO.'• k• O
LICENSED CONTRACTORS DECLARATION. " LIC: CLASS,NO.—DWELL. UNITS C
I hereby affirm that'I am licensed underprovtstons of Chapter 9.
ADDRESS.- S �:•Ro Va11.� B�RT(1 NO. 451937
(commencing'with Section 7000)of Divtsi6n.3 of-the Business + LIC. SEWER MAP H
and Professions Code,and my license is in full force anJ"ffect.. :+CITY San Caljriiil Ca'. CLASS C-39 :c BK PG. VALIDATION
:451937 . C-59,' SQ. FT. , NO..OF NO:OF" . t CHECK
License Number. � Ltc: Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor RandoZ k oofing.". Date 1-3Q-919• DESCRIPTION OF WORK Re-'roof houses: NEW ❑"° .$
:garages:and shed'.with. Firederee DD. ❑
❑I am exempt under Sec.'
BAP.C. .for this reason ' f��d ffberglas shingles. Class IIALTER ❑ ;
USE OF oX001:10REPAIR �•.,
Date: EXISTING.BLDG. SPD DEMOL ❑
SignatureAPPLICANT. TEL' FINAL
OWNER-BUILDER DECLARATION s (PRINT): Ran dol. ROOf3Ta NO.2^$$-.40 Q "
p . DATE
I hereby affirm that I am exempt from the Contractor's .License " ' . 529. k'. v alley Blvd.,-S 16 G. 91776
Law for the following•reason (Section 7031.5;'Business cind ADDRESS FINAL
Professions Code): PRESENT _ B
Y
"
r,+:!o:
❑ .I, as owner of the property; or mBUILDING. v
y employees-with ADDRESS
c •.
wages as their sole compensation,will do the work and � !�S,' ,.
the structure ts.not intended or offered for sale(Section LOCALITY
7044, Business Grid"Professions Code.)' MOVING•• TEL.
ElI,as.owner of.the property,-am exclusively.contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
ADDRESS
- tion 7044, Business and Professions'Code.) • -: " . a:�-tj-: '.
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY- :' 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, Civ..C.): SIDE
P.L. 'S� .
Lender's Name ..is t s.,.i i, �:L•"
LDMA Ref. ti
`I P:C. Fee$ Permit Fee
Lender s Address
I certify that I,have read this application and state that the i Issuance Fee--p4°�Q k:P"C ti
3 above information is correct. I agree to comply with all CountyInvestigation Fee
' ordinances and State laws relating to building construction, Total Fee -59.25 11LDMA Perm. #
..and hereby authorize representatives of this County to enter
3 upon the,above-mentioned'property for'inspection purposes. ;
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date'