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HomeMy Public PortalAbout4452-4454-4456-4458 TEMPLE CITY BLVD_Building__ p„,WORKERS COMPENSATION DECLARATION - k�,. i ,• - I h'grelty oJ(irrtl the, I have a certftcate of consent to self AP�LI, s TION F Ahfure.or cembcat¢ of Worker Compensation lruurance t, , BUILDING PERMIT+-•-- or a camhed copy hereof (Sec 3800 Lab c ) ' ' ' r COUNTY OF LOS ANGELES- BUILDING AND SAFETY-- Policy No Company - BUILDING ❑ Certified copy is hereby furnished H FOR APPLICANT JO FILL IN ADDRESS ❑ Certified copy is filed with the county budding mipec - I I hi/ysZ , Al dl y) y� V on department ' ADDRESS , 7 Date Applicant CITY � , l ..ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS -- 7 NO OF BLDGS - NEAREST ' COMPENSATION INSURANCE _ SIZE OF LOT O•r 1.-NOW ON LOT CROSS ST (Thr section` rs ($not or completed rf the perms a for one - �/y - _ -- ASSESSOR hundred dollar (f 100)or leu ) _ TEAR /J��� & tO�NO MAP BOOK ' PAGE PAROL I certify that in the performance of the work for which this OWNER /.46"1 NO p 1 USLE�Z IJDIMAP ) permit is Issued, I shall not employ any person in any manner l/ SPECIAL- - - -- - - d so as to become subject to the Workers'Com 'OEu '�� - - PP 1 pensaho Laws CONDITIONS V Date--"_ S� ppbwN .. CITY _ _ _ ZIP _ _ _ r \ NOTICE TO APPLICANT If, aft mak, t Cerhf, of ENGINEER - DISTRICT GROUP TYPE FIRE BY_ GA ram inARCHITECf OR TEL /I VZ O Exemption, you should bec e a to`the ken - EiE Compensation provisions oft L r is you m forth ADDRESS .S' r • G, �(•a /1� es �T / ZONE ,with comply with such.prov1 3C es m or this permit shall be - ✓ (/ K V deemed revoked F L CONTRACTOR NO V STATISTICAL TION APT LICENSED CONTRACTORS DECLARATION i LIC CLASS NO DWELL UNITS_ 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRE J NO 77ra (commenurp with Section 7000)of Drvnion 3 of the Business aril _ LIC _ R MAP ' Professions Code, and my license is in full force and effect Cm CLASS PG VALIDATION I i 50 FT NO OiNO OF CHECK License Number - LK Class SIZE STORIES FAMILIES / ONE s ' F , , VALUATION Contractor Date DESCRIPTION OF WORK LW v94W? NEWf�.�Q--(�Q-L�-- I❑ 21 4 Q 5 A I am exempt under Sec ADD V N ALTER # • • • • 23 B BP C for this reason r OF REPAIR- - - -- Date - EXISTING BLDG DEMOI _ 11.06144 _ _ NAL- Signature OWNER-BUILDER DECLARATION _ _ A��MT // �y'�s /,.+,"�nLN_O' 1 pA� -� , - 1,061,445 I hereby affirm that 1 am exempt from the Contractor's License ADDRESS/7350 &Cilf T+( V� /ON•orvB j s' - 0 124-85 Law for the following`reoson (Section 7031 S Business andA 16, Professions Code) - - -_ _ . -. r w , _ _ - _ ❑ I as owner of the property or my employBUILDING ees with ADDRESS wages os their sole compensation will do the work and i - 2 2 1 8 A the structure is not intended or offered for sole(Section LOCALITY ' ( 7044,-Business and Professions Code) - MOVING - -TEL 11 I as owner of the property, am exclusively contracting CONTRACTOR NO # • • • • 2 3 with licensed contractor to construct the Project (Sec _ _ -ADDRESS - - - -- - - I • 2-7 922 tion 7041 Business and Profession Code) REQUit CONSTRUCTION LENDING AGENCY - SET eq« ` YARD f1w1' OT PROP LINE WIDTH - - - - • • 279 2 2 LT` I hereby affirm that there n o construction lending agency for FRONTi � - � ` • ' � - I ,he performance of the work for which this permit is issued - - - P L - -- - - -- - `- id 1 - '0 6,0j —85 (Sec 3097, Civ C ) SIDE `� B �iebd�u�ntlXa_f, _ P L 2 2 11,9 A 7. Lender's Nome 8 �7 f. IOI�-Y� P C Tae f - Po, It Fee LDMA Ref 0 - - # • • e e • 1 ' = Lander a Address a� Ctin/ y /T _ 1 1 5877-5 - _I certify that I hove rood this application and state that the _ _ 'f_ 7 /� - I Ince Fee - .SV LDM4 P/C# above informamri u correct I agree to comply with all County Investigation Fee C 1� 1 587,75' ordinances and State lows relating to building construction _ __ _ Total Fee (J '� r / IDMA Perm u aril hereby authorize re ntatwes of this County to anter ' _ pr for inspection purposes -- - - - _ - 0 607-85 SH REVOW FOIL EXPLANATORY LANG"Ga re f iMni N -Data