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Home My Public Portal About5738AGNES AVE_Building (5) WORKERS'COMPENSATION DECLARATION City Of T Tri l P qty — \ hereby affirm that I have a certificate of consent to self A P P��CATION FOR/BUILDING PERMIT. insure, or o certificate of Workers'Compenstion Insurance, or , a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES v� - BUILDING AND SAFETY Policy No. 301687-8:tompany Arcadia '�_PH h45-4o- Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING / ADDRESS U Certified copy is filed with the county building inspec- BUILDING n u tion department. ADDRESS 5738 No. Ag o@- Ave° LOCALITY NEAREST / Date Applicant CITY ^Pm l i+v ZIP Ql 78n CROSS ST. •�� CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ONE MAP _�! hundred dollars ($100)or less.) TRACT BLOCK LOT NO. � f NO. C/ D TEL. SPECIAL CL I certify that in the performance of the work for which this OWNER T.4 TJ F,or. , NO. R —Q7 )t CONDITIONS �~ DISTRICT GROUP TYPE FIRE D BY permit is issued, I shall not employ any person in any manner CONST. so as to become subject to the Workers'Compensation Laws. ADDRESS �, NO° Agnes Ave e ` 99 Date Applicant CITY Temple City z, 91780 — pp STATISTICAL CLA �IFICATION APT. CONDO. U NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. O Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS Compensation provisions of the Labor Code, you must forth- with comply with such'provisions or this permit shall be ADDRESS SEWER MAPTEL. deemed revoked.. CONTRACTOR lha h a R nFi cr NO. 7g —lQK° BK. VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS rry Tall "Zr Rlv' NO. 253163 VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY L.A. Calif. 90032 CLASS C-39 $ 000;.00 [1 SQ. FT. NO. OF NO. OF CHECK License Number 25313 0— Lic.Class J9 SIZE STORIES FAMILIES ONE ❑ $ Contractor ROOF1nP Date DESCRIPTION OF WORK R r f r n r a E O f I am exempt from the ADD licensing requirements as I am a IIS Only 1Jd� 240( L.om O Shingl S licensed architect or a registered professional engineer ALTER ❑ FINAL acting in ,my professional capacity (Section 7051, DATE REPAIR93 Business and Professions Cade). USE OF NAL / r EXISTING BLDG. DEMOL FINAL Lic.or Reg. No. _Date APPLICANT TEL. U OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License 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 [ADDR LITY 7044, Business and Professions Code). NG TEL. z 3 8 5 7 A I, as owner of the property, am exclusively contracting RACTOR NO. 0 0 0 0 0 1 with licensed contractors to construct the project (Sec- ESS � � • tion 7044, Business and Professions Code). UIRED TOTAL SETBACK FROM EXIST. 2 a o 2 5 0 0 CONSTRUCTION LENDING AGENCY BACK YARD Hwy PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for NT a a 'a 2 5 Q o the performance of the work for which this permit is issued (Se$. 3097, Civ. C.). E O 1,23-81 Lender's Name (J Lender's Address ee$ Permit Fee =00 II certify that I have read'this application and state that theIssuance Feeabove information is correct. I agree to comply with all County igation Fee ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter / a u on �abov -ment' pr perty for i pection purposes. ^ `� a �� QD SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applico t or Agent Dii= ©s