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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'