HomeMy Public PortalAbout4442 TEMPLE CITY BLVD_Building__ 1, TION
L ' WORKERS' COMPENSATION DECIARk -
sI lief! offem that 1 have a cenificate of-consent to ,elf gppLlCAT�ON -FOR BUILDING PERMIT
-tnsuru •o certficate of Workers Compensmlo Imurance
• . a4 ?candied copy thereof (Sec 3800, Lob C )- _ COUNTY OF LOS ANGELES BUILDING, AND SAFETY
Policy No No `Company _• BUILDING O 7
❑ Certified copy Is hereby furnished FOR APPLICANT TO FILL IN ADDRESS o�
❑ Certified co is filed with the county builds I BUILDING'
copy ty rinP� ADDRESS
+ hon deportment _ _
aTY EH E C ( zIP q g a DULm
Oats Applicant /10 3QSs N�ON LOT a NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ` SIZE OF Ia7 CROSB ST -
COMPENSATION INSURANCE' '' ASSESSOR
(This section need nat•be completed if the permit Is far one TRACT&B 34 BLOCK OO t�G LOT NO MAP BOOK '�/ Z PAGEQU PARCEL d L
hundred dollars ($100)or less ) • OWNER 0 eC0 �i- 0 FFRO No
'� MAP •� �a6
I certify that in the performance of the work for which this 'I a SPECIAL n
permit Is Issued, I shall not employ any person in any manner ADDRESS 4 1 TEM YL.b eI•t V L V Dq CONDITIONS O
so as to become subject to the Workers Compensation Laws CfTY�U H P LG CITY ZIP q so U
(/ K
Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE BY Q
NOTICE TO APPLICANT If, after molding thin Certificate of ENGINEER
NO 0� CONST..�J ZOO �s Gi
Exemption, you should become subject to the Workers' ADDRESS S!�
Compensation provisions of the Labor Code, you must forth- Z
with comply with such provisions or this permit shall be ` TEL STATISTICAL CLASSIFICATION APT Z
deemed revoked - OOMR.ACTOR NO LIC CLASS NO 2 DWELL UNITS_
LICENSED CONTRACTORS DECLARATION NO
I hereby affirm that I am licensed urder provisions of Chapter 9 ADDRESSNOSEWER MAP
(commencing with Section 7000)of Division 3 of the Business Cin, /
CLASS BK ! -PG D VALIDATION
and Professions Code,and my license in;n full force and effect NO CHECK
License Number Uc Class— SIZE FT ,' NO STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK /— NEW
- ❑ )afe d :
Contractor rD
V
❑I am exempt under Sec f4 45�_ OCC GP ALTER ❑
B$P C for This reason X�`eG'(G rN-�w,/.G t " REPAIR E) $ _
Dole USE R CS't oN 4v 1 L } DEM"01 ❑
EXISTING BLDG
) � I.
TEL
Signature APPLICANT pRj1�n1 L L e NO ✓ 44-7 `7 FINAL
OWNER-BUILDER DECLARATION L {fir DATE ht T T
I hereby affirm that I am exempt from the Contractor s License ADORREmss:,�fiLEf2 _�- C Lo E �Tr L.J1 V I FINAL —i
Low for the following reason (Section 7031 S, Busmess and B
I r f Ions Code) — ENT - y
Typ��ys BUILDING T 1iBIC
U I, os owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and - '
LOCALITY TOTAL 524 Jia
the structure Is not intended m offered for sole(SectionTEL
7044, Business and Professions Code ) MOVING - ^ -
CONIRACTOR NO
❑ I as owner of the property, am exclusively contracting �d
with licensed contractors to construct the protect (Sec- - ADDRESS
tion 7044 Business and Professions Code ) IRED YARD HWY MAL CK FROM EXIST - ' r
CONSTRUCTION LENDING AGENCY SET -
I hereby affirm that there iso construction lending agency for FROM - _ ` IJI]hI�-i!1_IJ1 of l_,'•1
the performance of the work for which this permit is issued P L /'
(Sec 3097, Civ C ) SIDE •b94`
S Lender's Nome PC Fee f jDhV+Ref ii^^
[ - Perms Fee `J ►
Lender s Address
LDMA P/C It
I certify that I hove read this application and state that the Inaar,ce Fee 3r
above information Is correct I agree to comply with all County Invesag ii,n Fee _ _ h
ordinances and Slate laws relating to budding construction, Total Fee N TDMA Perm -
and hereby authorize representatives of this County to enter , _ - _
upon the above-mentioned property inspection purposes ,
R 6EE REV!!SF FOR IIXRANAT- LANGUAGE -
S,geoiure of Apphmnt or Ag-,r/