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