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HomeMy Public PortalAbout5851TEMPLE CITY BLVD_Building (2) WWORKERS'COMPENSATION DECLARATION affirm that I have a certificate of consent to self h r a certificate of Workers'Compensation Insurance, APPLICATION F ORBUILDING P E RM I T LA, ified copy thereof(Sec. 3800, Lob.��C ). , i COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. f Company �Y'� •- BUILDING �+ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .� ' � C4 A-�9'e� Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS ��W /e LOCALITY x NEAREST Date Applicant CITY t ZIP CROSS ST. - CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE I PARCEL (This section need not be'completed if the permit is for one T 6 -1BLCICK �' LO7 USE ZONE O. hundred dollars($100)or less.) TEL. ��,���� z2 7 SPECIAL }. I certify that in the performance of the work for which this OWNER �Q/e �OG�Ld 0 'NO.a d 7 7�3J.d CONDITIONS permit is issued,I shall not employ any person in any manner /� / DISTRICT .GROUP TYPE FIRE PROCESSED BY 4 ADDRESS ���6 A�S (,t A CONST. ZONE U so as to become subject to the Workers'Compensation Laws. �V IV CITY e le �� Date Applicant ARCHITECT OR ZIP Tf STATISTICAL CLASSIFI ION APT. CON NOTICE TO APPLICANT: If, after making this'Certificate of ENGINEER NO. CLASS NO. DWELL. UNITS � Exemption, you should become subject to the Workers' p� Compensation provisions of the Labor Code, you must forth- ADDRESS SEWS M with comply with such provisions or this permit shall be TEL�J deemed revoked. CONTRACTOR "'l7�0 IJS� �S N6A 6d-,�_ 07 VAP 0 BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATIONLIC. +� G�j I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 9®-- E /.Z! vim-'—N6 0O / 0 VALUATION (commencing with Section 7000)of Division 3 of the Business andP n LIC / Professions Code,and my license is in full force and effect. CITY �.QS AN bele Ci CLASSe ��/ SQ.FT NO.OF NO.OF CHECK ;DATEL +License Number 020 /0 Uc.Class -/0-� SIZE STORIES ®�� FAMILIES Dd'Q ONEContractor �+A/- !TeaU 5 ;GS Da}e DESCRIPTION OF WORK �STAB/ "H P4 NEWI am exempt under Sec. it 5 ! (50Osr(�, 4ADD ❑ALER ❑ INA /B.BP.C. for this reason ! REPAIR / �e! / � USE OF L / DEMOL FINAL ? c n o o Date' EXISTING BLDG. ARbe J�l7 Q ❑ B APPY APPLICANT TEL. o Signature OWNER-BUILDER DECLARATION PRINT NO. 4 g`a ' I hereby affirm that I am exempt from the Contractor's License 7a o LI 9, 5• C ;_ Law for the following reason (Section 7031.5, Business and ADDRESS. Professions Code): PRESENT ) — ❑ .BUILDING I, as owner of the property, or my employees 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. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SETBACK 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. tSec. 3097, Civ. C.). SIDE 0 P.L. ? Lender's Name 4 3 P.C.Fee$ Permit Fee i Lender's Address I certify that I have read this application and state that the Issuance Fee ve s 0 ( above information is correct:I agree to comply.with all County• Investigation Fee a ordinances qnd.State,laws relating•to'building conn structio , Q a f and hereby authorize representatives of this County to'enter Total Fee. M� p• upon the above-mentioned property,for,inspAction•purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ®s