HomeMy Public PortalAbout5753TEMPLE CITY BLVD_Building (2) I
WORKERS'COMPENSATIQN DECLARATiOV /• "
APPLICATION FOR BUILDING PERMIT �
I hereby affirm that I have a certificate of conser0P}a sE'!f
insure, or a certificate of Workers'Compensation Insurance,
or.a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
❑ Certified copy is hereby furnished. J FOR APPLICANT TO FILL IN ADDRESS 7�' C '
❑ Certified copy is filed with the county building inspec- BUILDING -,/ L
tion department. ADDRESS � 7-- c hvp �Lc nf, 19/ 'ro
Date Applicant CITY C4 ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT D X S NOW ON LOT CROSS ST. n/
(This section need not be completed if the permit is for one ASSESSOR
-hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER /2�Z NO. 5=�3 NO. 661
permit is issued,I shall not employ any person in any manner + C, ���� SPECIAL f�
so as to become subject to the Workers Compensation Laws.• ADDRESS��>�3 ,/HSG G�y CONDITIONS X0.7
f CITY C �^ •ZIP /1 7 O ad
ate 3 Ah Applica
NOTICE TO APPLI ANT: If, a ter making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRO SSED BY, O
ENGINEER NO. CONST. ZONE
Exemption, you should become subject to the Workers' ]�/ U
Compensation provisions of the Labor Code, you must forth- ADDRESS �iL'• -J. V =� IL
with comply with such provisions or this permit shall be" U)
TEL. STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC, — CLASS NO. et&-e DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CIT - CLASS BK. /-PG. .� VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
ALUATION •��
Contractor Date DESCRIPTION OF WORK .+l AD ❑❑ $ 1 [�
❑I am exempt under Sec.
ALTER IAI
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF p
EXISTING BLDG. ✓ DEMOL ❑
Signature APPLICANT TEL. FINAL 7
OWNER-BUILDER DECLARATION PRINT) y / 1^ 10. S•7 DAT r'
1 herebyaffirm that I am exempt from the Contractor's License r�
Law fothe following reason(Section 7031.5, Business and ADDRESS)7&.3 /1/• oflvf C C/7Al, ! •�' �' FIN ^C 1 A
B r.
Professions Code): PRESENT l�
❑ BUILDING a i! o o 0 o a 1
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY -^f ' o o
the structure is not intended or offered for sale(Section C 33 6 7
7044, Business and Professions Code). MOVING �� TEL.
❑ CONTRACTOR rte'" NO. r 0 n 3 f 7 C jJ
I,as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS n-
tion 7044, Business and Professions Code). C 5.G 8 .
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP. LINE ETBACK FROM 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
'o
P.L.
d Lender's Name via,
-� LDMA Ref. #
Lender's Address P.C. Fee$ Permit Fee
@ I certify that I have read this application and state that the Issuance Fee U G LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee / �/
d ordinances and State laws relating to building construction, Total Fee 3�o. ,] LDMA Perm. #
and hereby authorize representatives of this County to enter
S pgp4 e above-mentioned property for inspection purposes.
� / J , 3�P•�O �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date Oo