HomeMy Public PortalAbout4335 TEMPLE CITY BLVD_Building__ ORKERS COMPENSATION DECLARATION \ It �I
heeeb afflrtq-tlwt I.ha,ey certificate of tensest to self — \gppLICATION FOR BUILDING- PERMIT (IIS
` mute;or a certificale'af Worken' Compensation Insurance,
or a certified copy thereof 3800, Lab C )
Policy NZ Y3 Ccvpany S-tA'W F&nal. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished FOR APPLICANT TO FILL IN AUID gESS �j�lGj Tt/L�
XI� Certified copy is filed with the county building inspec- BUILDING p
tion-department AODRFSS )! VD LOCALITY
0— %� /j/J/)�L /' ,t NEAREST
Date Applicant i/-s//�iY�/Y/+/-.\� CITY l.l' ZIP V CRO555T
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT /C16?.S"Z NOW ON LOT
MAP BOOK P PARCEL
(This section need not be completed if the permit is for one USEZONE
hundred dollars($100)or leu ) TRACT BLOCK LOT NO " NO O
rf�+ TEL /� SPECIAL
I certify that in the performance of the work for which this OA'NER r T W/sZG NO Z�/ CONDITIONS 0-
permit
permit is issued, I shall not employ any person in any manner /�-��� - DISTRICT GRWP TYPE FIRE SSED BV V
so as to become subject to the Workers'Compensation Laws ADDRESS '�•� ' '^'•�M C ZONE
T Q J �_� Im
O
Dote Applicant CITY • � ZIP TEL
%(7� ATLSTI('AL CL4551FKATION APT C 0
NOTICE TO APPLICANT If cher making ilia Certificate of su
ENGINEER NO CLASS NO DWELL UNITS_
27
Exemption you should become subject to the Workers !� -[ IL
Compensation provisions of the Labor Code you must forth ADDRESS , „ _ C.x'T4//J - sY• -9X06' i SEWER MAP . nn
Z
.
with comply, with such provruons or Ilio permit dull be
deemed revoked CONTRACTO& 01,54L" _ )4Q L 70ye BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION ? LIC
I hereby offmn that 1 oro licensed under provoions of Chapter 9 ADDRESS K Z NOqq6VIbr? VpLU
commencing with Section 7000 of Division 3 of the Buuness and ��[` B O
(commencing
e o m �ioCode, and my license in full forand effect CITY . - 7/d0IWO '
SO FT - NO OF _ NO OF CHC4( -
License Number. ( 6 q LIC Closu, SIZE STORIES IFAMILIES ONE
1,. j ='4 � 22�A
Contractor �CiL�I Date / DESCRIPTION OF WORK V �I . . . . 23
.a ADD
I am exempt under Sec L /�
ALTER FINAL 2 . 5 3 5 5 0
B&P C for this reason REPAIR DATE
USE OF FI • ° c, 5 5 0 6
EKIsnNG BLDGDEMOL
Signature Date O 8Y n 02 0-8 (1
OWNER-BUILDER DECLARATION A (PRINT) QN NO �3 I3Z
I hereby affirm that 1 am exempt from the Contractor's License / .s I i'J1J 41449/� �'Q ► �/
Law for the following reason (Section 7031 5, Busmen and
Professions Code) ON
BUILDING
1, as owner of the property, or my employees with ADDRESS Q S 6 8 A
wagm 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# • • • • •
1, m owner of the property, am exclusively contracting * 64Q50
with licensed contractors to construct the project (Sec- �
tion 70", Business and Professions Code) ADDRE _
(RED YARD HWY TOTAL CK PROM EXIST
CONSTRUCTION LENDING AGENCY ROD u WIDTH . t • • 6 4 Q 5 0 E
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 I Q 1 2-8 4
jSec 3097 Civ C ) SIDE
PL
p Lender's Name
C P C Fee j Perron Fee
Lender's Address
�Y I certify that 1 have read this apphcatror and state that the Isuiance Fee
above information is correct 1 agree to mmpty with all County Investigation Fee
ordinances and State jaws relating to building construction, - Total Fee
and her out orize representatives of this County to enter I
upon the prof»try for inspection purposes
/ ( -!� SEE 4NYOtf!FOR EXPLANATORY LANWAGE
^ ODs
ignA &um of Applicant or Agent Data