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HomeMy Public PortalAbout5801-5803-5805TEMPLE CITY BLVD_Building WORKER'COMPENSATION DECLARATION j ent to sf insure,boraafcertif cafirm tharte of Wo ke s'tCompensat on insurance, APPLICATION FOR BUILDING PERMIT or a certified Fopy thereoflSec. 3800, Lab. C.) Policy No. a�'_i71�f�•,l�7 ompany s' All COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING V .0 ADDRESS ``'r �V �( Certified copy is filed with the ou ty building ' ec- BUILDING tion d9partnprit. ADDRESS O/ —03 .rte Date Applica CITY • ZIP LOCALITY ERTIF CATE OF EXEMPTION FROM WORKERS' No.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL TEL. USE ONE MAP I certify that in the performance of the work for which this OWNER . NO NO. permit is issued, I shall not employ any person in any manner ADDRESS 0 �I `ST �j/� SPECIAL a so as to become subject to the Workers'Compensation Laws. o CONDITIONS O Date Applicant CITY .f ZIP ( U NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GRUP OTYPE Fig PROCESSED BY O Exemption, you should become subject to the Workers, ENGINEER NO. ()n CONST.` eZylB{'(d U Compensation provisions of the Labor Code, you must forth- ADDRESS J9 1- V W with comply with such provisions or this permit shall be 0.' deemed revoked. No , STATISTICAL CLASSIFICATION APT. Do. N CONTRALTO �f �. U) LICENSED CONTRACTORS DECLARATION ((^^ LIC, CLASS NO.��DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS � J% /©iaJ NO. ,?6 9 (commencing with Section 7000)of Division 3 of the Business and /l LIC / / SEWER MAP Professions Code, and my license is in full force and effect. CITY (C7 7. CLASS Gp/ BK PGVALIDATION �Q/Cd �— / Sq.FT. N0.OF NO.OF CHECK License Numberw-:57-66 �� c6 7 Lic.Class�p SIZE IN FAMILIES ONE Controae � AIW,Aj� Date O �t�o O DESCRIPTION OF WORK NEW ❑ VALUATION ;281 a 2 A ❑I am exempt under Sec. " /jJ q ❑ $ (/{ 0 0 p I f� /// ISE [+ �S ALTER ❑ o o B.BP.C. for this reason 6 .•� REPAIR ❑ $ Q 7—87 Date: USE OF EXISTING BLDG. L DEMOI ❑ Signature APPLICANT TEO.L. t�y FINAL [- 'o/(// OWNER-BUILDER DECLARATION PRINT NDATE I hereby affirm that I am exempt from the Contractor's LicenseA �� v Low for the following reason (Section 7031.5, Business and ADDRESS itlr"V6 FINAL Professions Code): 1 11 PR By i El BUILDING I, as owner of the property, or myemployees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. j with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK F 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. Lender's Name LDMA Ref. #Lender's Address P.C. Fee$ Permit Fee fJ ' I certify that I have read this application and state that the I Issuance Fee LDMA P/C q above information is correct. I agree to comply with all County Investigation Fee ordinances and State lawsrelating to building construction, Total Fee LDMA perm. R 3 and here thorize repress tatives of this C unty to enter � upon th ab ve-mention erty for ins ion Pur oses. '` �Q ? SEE REVERSE FOR EXPLANATORY LANGUAGE - Signature of Applicant or Agent Dat � r