HomeMy Public PortalAbout4522 TEMPLE CITY BLVD_Building__ II
. - -- APPLICATION FOR BUILDING PERMIT �]
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILaNG ADDRESS ,cZZ 1 eu� Q, C�
I hereby affirm that I haw a certificate of consent to salt Retire BUILDINID ADDRESS � A
or a�certrlcate of Workers Compensation Insurance or a certified 1-I 6 -
copy thereof (Sec 3800 Lab C) CITY /P ZP9 LOCALITY
Company SIZE OF I-Orf NO OF BLOCS NOW ON LOT
❑ Certified Copy Is hereby furnished NEAREST CROSS ST
❑ Certified Copy Is filed with the County building Inspection TRACT BLACK LOT NO -
depertmentUSE ZONE MAP NO
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Date Applicant ASSESSOR MPP BOOK - PAGE PARCEL ,
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS
EL fJ0
COMPENSATION INSURANCE GI91 LO WITHIN 1000 FT OF SCHOOLI YES NO
(This seSectionneed riot he cortpleted If tris permit a ADDRESS for one hundred O !'L
DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
ddlars IS 100)or Las)
I certify that In the performance of the work for which this permit Cf(v �r� LP /,// 15-Ob 9
G Issued I shall not employ any Demon In any manner so as 10 ARQIITECT OR ENGINEER TEL NO J
become subject to the Workers CCO/mpenaatio Laws STATISTICAL CLASSIFICATION AFT
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Date 2. Applcallt /�'�u'�` l� ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT If after making the Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you should become subject to the Workers CONTRACTOR TEL NO SET BACK YARD FIWY PROP UNE WIDTH
Compensation provImns of the Labor Code you must forthwith A C yTj- "?1
ROM
comply with such proveKms or this permit shall be deemed revoked gppLq /� uc NO P L
!! 6 w %s/�.�� 6 v �� SIDE
LICENSED CONTRACTORS DECLARATION DTTY uc c P L
I hereby affirm that I am licensed underprovelors of Chapter B • SEWER MAP
(commencing with Section 7000)Of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FP1.1ilES
Professions Code and my license Is In full force and effect I NEW ❑ BK PG d
13 DESCRIPTION OF WORK ADD ❑ VALUATION
Lcense Number —Lc Class - �3 0
Cmtrac(pr��'.L .caa Date 4'—.?� �G ALTER ,EI/ $ T �O ,(`,T.i
4 C C REPAIR L'J - O
❑ am exempt under SecIr
$ o"'Ii. J7 50.50 U
BBPC for this reason V CQ i11, DEMOL ❑ LOMA PAC
r Date USE OF EXISTING BLDG URM ❑ �1. a
Sgnature AICANT IPFWIT() TEL NO LDMA Perm♦ tkLT.T Z
❑ I as owner of the property or my employees with wages as �_ =O 3307
their sole compersallon will do the work and the structure 6 ADDRESS F
37
not Intended or offered for sale (Section 7044 Business and ?0 It W L. 02 (J1 .)-p FINAL DATE
'J p _ a 2 ITEM
Professions Code) V THE APCJGNT OR FUTURE WL OCCUf NT HNIDLE A HAZAROOUa MATERIPL
❑ I as owner of the properly am axcWsrre fAnimOtl vnih OR A MIXr E CONTAINING A HA RDous MATERu EOUAL To OR GREATER T N THE 17a TOTAL .�' Vd g7
N n9 AIKMMIa SPF p ON THE Iw.NaDcua MATSFv uFORMAn GUOE2 FlfUL > TOTAL
.
licensed contractors to construct the project (Section 7064 YES El NO El Vj�fjL�'� '� G7iJ17 �K 380.87
Business and Professions Code)
wu THE INTENDED USE OF THE BUWNO BY THE APPUCANT OR RnURE BLILDLVO .011
CGCLRINT REOLIeE A PERMIT FOR GONSTRUCTNJN OR MOU'FX;ATION FROM THE SOUTH
n I Vf1Ntl7L VL
CONSTRUCTION LENDING AGENCY COAST AIR DUALITY MANAGEMENT DISTRICT ISCADMDI SEE PERMITTING cHCCXLST FOR
oUIDELess
I hereby affirm that them Is a construction lending agency for YES❑ NO❑ �tfNS•A�t1_ �
w the performance of the work for when this permit Is Issued(Sec N.+t+T+r.rI,ALAIJI 4/27/93
q , IINVE READ THE WJJACOUS MATERNLe INEOfAIATpH GIIOE ANTI THE$G40MpF£RMTTINIG i Atli 1�2/
3097 GV C) , CHECKUST I UNCERUAF MY REIX 161ENTS UNDER THE LOS ANGELES COUNTY GODE
TIRE 1 Cl4PTER 220 MOTIONS 2 20 100 THROUGH 2 20140 OCIN'ERNMD HAZA Ie 9394 j 191
Lender a Name MATERIALS PEPOTTT4D AND FOR p NING A PERMIT FROM THE SCIDND
o Lenders Address ,
aN•Fnw.r T
0
I f perjury
that haw read this applicmatron ism and state under penally
comply
8 of peRufy that the ebow information is correct I agree t0 comply PC FEE PERMIT FEE I ,
with all county ordinances and State laws relating to Wilding o 4.
Construction and hereby authorize representatives of the County ISSUANCE FEE � O
to enter Ippn iha above- mperty for Inspection purpoaes
'i�•L-f?�-- WVESTIGATION FEE �_) SO TOTAL FEE 85 0. 31
.
T / SEE REVERSE FOR EXPLANATORY LANGUAGE