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HomeMy Public PortalAbout4829 TEMPLE CITY BLVD_Building__ WORKERS COMPENSATION DECLARATION hereby affirm that haveaamhamp -of cannon, to self APPLICATION FOR BUILDING PERMIT insure, oro certificate of Worr kers Compensation Insurance ' or a cenified'copy thereof (Sec 3800, Lab C ) - COUNTY OF LOS ANGELES BUILDING AND SAFETY Polity No Company BUILDING_ ❑ Certified copy Is hereby furnished _ FOR APPLICANT TO FILL IN ADDRESS Lh2q /LJ 1 ❑ Certified copy Is filed with the county building Inspect ' ADORING DING f``D $ ^ hon department Date Applicant CITY I (Al- ZIP D LOCALITY 09 CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT NEAREST FT G COMPENSATION INSURANCE _ _ LOT r4o _ ASSESSOR C(This section need not be completed If the permit Is for one TRACT BLOCK MAP BOOK PAGE PARCEL undred dollars ($100) or less ) ``,, TEL I OWNER /s'1I 5'4W 0494,NO AQ17025,5ONE MAP I certify that in the performance of the work for which this ,6 permnns Issued, I shall not employ any person In any manner ADDRESS - 'C �4 I, t �prpRIONS O so as to become subleO to the Workers'Compensation Laws y.� w p ry _ - ZIPce Dote $ 1 Applicant 4;;44XV— ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O L NOTICOTO APPLICANT If aft ungung this m s Certificate of ENGINEER — NO CONST ZONE Exam hon you should beta a ub ect to the Workena 19 - ' P Y C ^ << Compensation provisions oft bor Code, you must forth- ADDRESS ,, 3 "W N with comply with such provisions or this permit shall be CONTRACTOR � STATISTICAL CLASSIFICATION _ APT CONDO Z deemed revoked IUC CLASS NO 2 DWELL UNITS__ LICENSED that m licensed un DECLARATION ADDRESS NO I hereby affirm that am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of DIVIbIOn 3 of the Business LIC and Professions Code,and my license m infull force and affect _ CITY CLASS BIc PG VALIDATION SO FT NO OF NO OF CHECK - 1 License Number Lrc Clogs SIZE STORIES FAMILIES ONE VALU'A7{LON a Contractor Date DESCRIPTION OF WORK NEW _ ❑© $, �.{511�, F� CT.T 7v.Vl• /^ _/ CC// ► 7l O ❑I am exempt under Sec C- t �— FOOD}� .r.' ALTER ❑ 1 ITEM B&P C for this reason ❑ S _ _ Date EXISTING BLDG P5 USE OF cella ❑ TOTAL 78 .00-� g1 Signature �' APPLICANT I - _ TEL FINAL GHEGY, r'�•W OWNER-BUILDER DECLARATION PRINT) —) N r[(F n10 ,3'0lJ 0 39 DATE l�j CHANGE - . - .DU I hereby affirm that I am exempt from the Contractor's License S �� i/1?&'-1 N T,Q` e 6,1—(3" 7<t Low for the following reason (Section 7031 5, Business and T6 FIN tyesatons Code) I X _ _ -LDING By0000-0001 e/16/E9 _ I, as owner of the property, or my employees with+ AADIDRRESS wages os their sale compensation,will do the work and. 1928 1 Ali iC:rjb the structure Is not Intended or offered for sale(Section: LOCALITY ► ` 7004, Business and Professions Code ) I MOVING- - TEL - ❑ I as owner of the property am exclusively contracting CONTRACTOR NO with licensed mntractors to construct the protect (Sec-' ADDRESS tion 7044, Business and Professions Code ) "CONSTRUCTION LENDING AGENCY REQUIRED I� YARD HWY AL p LIN CKIROM I - - - - - WIDTH I hereby affirm that there Is a construction lending agency for FRONT I the performance of the work for which this permit Is Issued P L I (Sac 3097 Civ C ) SIDE PL Lender's Name Per. �J I� LDMA Ret • Lender s Address P C Fee S _ 2 _ y' it Fee / g I certify that I hove read this application and state that the Issuance Fee l d r Jt/ LDMA P/C 0 above Information Is correct I agree to comply withal[County Investigation I. -_ A _ ordinances and State lawn relating to building construction, Total Fee LDM4 Perm 0 Q and hereby au,honze representatives of this lY9 upo t e re-mentioned roperty for Inspection purposes _ SEK RKVERSS FOR EXPLANATORY LANOUAG! a ro of Applicant w Agent Date