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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