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HomeMy Public PortalAbout5721-5723 RENO AVE_Building__ ' I WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent self , APPLICATION. FOR ;BUILDING P E RM I T insure, or a certificate of Workers'Compensation Insurance, � .or a certified copy thereof(Sec. 3600, Lab. C.) COUNTY OF LOS ANGELES ! BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 5721-23 Reno .Street ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5721-23 Reno Street Date Applicant CITY Temple City zip 91780 LOCALITY Temple City NO.OF BLDGS. NEAREST Elm Avenue CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT 5387 BLOCK 11 LOT NO. 13 MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) OWNER CITY OF TEMPLE CITY No . 285-2171 USE ZONE MAP I certify that in the performance of the work for.which this NO. permit is issued, I shall not employ any person in any manner ADDRESS' 9 701 Las Tunas Drive SPECIAL CONDITIONS 06 so at.to become subject to the Workers'Compensation Laws.• � � QU CITY ZIP 91780 Date Applicant ARCHITECT OR TEL. a! NOTICE TO APPLICANT: If, after making this.Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption, you should become subject to the Workers' I CONST. ZONE 0 Compensation provisions of the Labor Code, you must forth- ADDRESS 5.08 R-3 V 3 UL with comply with such.provisions or this permit shall be TEL. N Charlie Gann ( ) STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR NO. _ LICENSED.CONTRACTORS DECLARATION LIC. CLASS NO. 23 DWELL. UNITS —2 ADDRESS 9879 Union St. NO. 192558 I hereby affirm that I am licensed under provisions of Chaptere) �• SEWER MAP ' (commencing with Section 7000)of Division 3 of'the Business• LIC. Glen Avon and Professions Code,and my license is in full force and'effect. i CITY ' CA CLASS C-21 BK-V PG. 9i VALIDATION• SQ. FT. NO. OF NO.OF CHECK License Number Lic. Class I SIZE STORIES FAMILIES ONE y VALUATION Contractor Date DESCRIPTION OF WORK 14 I-L 1J NEW ❑ $ E]1 am exempt under Sec. I Du lex with detached 2-car ADD El ► • ALTER ❑ B.&P.C. for this reason ara e' 588 sf & 815 sf REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature : APPLICANT TEL. FINAL f OWNER-BUILDER DECLARATION (PRINT) NO. DATE I�--z I hereby affirm that I am exempt from the Contractor's License ' ADDRESS Law for the following reason (Section 7031.5, Business and FIINAA © , I-1 FEE Professions Code): PRESENT ❑ BUILDINGI, as owner of the property,Y• or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY I f�l�f -i?LE) t f i the structure is riot intended or offered for sale(Section ; , z _ T. 7044, Business and Professions Code.) MOVING TEL.❑ C r,, CONTRACTOR NO. 5+495 1 F'M ti o y i I,as owner of the property,am exclusively contracting • with licensed contractors to construct the project (Sec- rADDRE tion 7044, Business and Professions Code.) TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY ;Fee ; PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for j the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). I Lender's Name PermitFeeLDMA Ref.# Lender's Address1 certify that I have read this application and state that the I Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County n ordinances and State laws relating to building construction, Total Fee LDMA Perm.# and hereby authorize representatives of this County to enter, upon the above-mentioned property for inspection purposes: ; o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature bf Applicant or'Agent Date