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Home My Public Portal About4830 TEMPLE CITY BLVD_Building__ WORKERS COMPENSATION DECLARATION APPLICATION - FOR BUILDING PERMc _ IT — T 19649hy cH'rm dot I�tave a ceFtlhcate of consent to self - - insure or a certificate of Workers Compensation Insurance,- - Qr o'certified copy thereof (Sec 3800 Lob C') - - - - ° • -- - - I 11" . , , - . i „ 1 , . COUNTY OF LOS ANGELESBUILDING,AND SAFETY Policy_No Company -Q _ • - Q 1 + Certified copy is BUILDING hereby furnished f , FOR APPLICANT TO FILL IN ADDRESS ' Certified copy is filed with the county building mspec - _ BUILDING { •-�- /� tion department i , ADDRESS 8.JyO te'+� .'�'+ 1Applicant CITY T �4! C.L 17 LaZIP 0 O LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS - - -- ' r._ COMPENSATION INSURANCE • ' SIZE OF LOT GO X �6� NOW ONLOT � NEAREST LID 'h tA (This section need not be completed if the permit is for one —- TRA�- — ��- - — LOT tJ0 _ ASS BOOK - PAGE PARCEL, _I hundred,dollars($100)or less ) _ r + I" ' - OWNER ulU1t_/LT� k(�Ll C�5 (.I NO TEL 2de-�03 115E ZONE + f certify that in the performonce of the work for which this -t- NO , > permit atissued, I shall not employ any person in any manner ADDRESS 4830 l -�-t BIV CONDITIONS Q SPECIAL so'as to become subject to rhe Work Compensation laws ._ + • ' ' ' CITY TC.IM C: ZIP !11-79O _ - - - - - - - , m Date ' Applicant" a)-U" "-- s - Q NOTICE TO'APPLICANT •If aher'inaking'this Certificate of ENGINEER ARCHITECT OR NO DISTRICT _ GROUP TYPE i FIRE _ PROCESSED BY 1 Exemption 'you'should become subject to"the WorkersCONST , ZONE Compensation provisions of the Labor Code you must forth ADDRESS _ _ _ with comply with,,such t provisions or thls,permlt shall be - - - - deemed revoked i,.., , , TEL STATISTICAL CLASSIF TION APT CONDO, r ' CONTRACTOR NO LICENSED CONTRACTORS DECLARATION - - tic - CLASS NO DWELL UNITS_ - I hereby off that I am licensed under provisions of Chapter 9 . ADDRESS NO r (commencing with Section 7000)of Division 3 of the Business and _ _ _ _ LIC �R� ' Professions Code and my license is in full force and effectBK CITY CLASS - - - ^ - VALIDATION FT NO CIF NO OF _ CHECK ' VALIDATIONLicense Number • , _ Lic Class SIZE - STORIES FAMILIES Ott VALUATION i Q�Q Conticctor ,-v• A +t • •'Date DESCRIPTION OF WORK - - - - NEW - i -- �3 9 Q 4 A Fn (nL II f '1 1:1I am exempt under Sc r00\4C . . ADD # e e e e e 1 - ALTER B 8P C far this ieason _ dt�LJlk REPAIR _ : I ---126.88 e_1 .Z88 ' Date _ USE OF DEMIX EXISTING BLDG • i 2 Q,8 8 Signature _L _ _ _ __ _ APPLICANT TEL FINAL ,( OWNER-BUILDER DECLARATION SIM � _ DAIS -1 hereby affirm that I am exempt from the Contractors License _ - _ _ _ _ _ _ --- _ Q ,_p 3 1:8 b Law for the following,reason (Section 7031 5, Business and ADDRESS flNA t Professions Code) RRM� ® BUDDING - I_ as owner of the property, ormy employees with ADDRESS _y _ wages as their sole compensation,w[II do the work and i the structure is not intended or offered for sale(Section LOCALITY 7044-Business and Professions Code)- - - MOVING - - TEL - - - - - - - -- - i 1, as owner of the property am exclusively contracting CONTRACTOR NO 'with licensed contractors to construct the project (Sec hon 7044 Business and Professions Code) ADDRESS REQED SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY _ -SET BACK YARD I1N'V PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT + ` the performance of the work for which this permit is issued PL (Sec 3097 Civ C ) 510E 211l CtAC _ PL Lenders Name ALE' x/1=L:i GFS CLI P C +•-'-- 4830 T{�Ca` to-911 NVd, - Fee f -- - Perm,Fee , �l y LDMA Ref If Lender,s Address Y J 0 T I certify that I have read this application and state that the Invonce Fee- IDMA P/C Id- above information is correct I agree to comply with all County Inveo gi itron Fee _ - -` -` _ _ordinances and State laws relating to building construction, Tocol Fee ' t and hereby authorize representatives of this County to enter - LDMA Perm-R , ` $ uporAe above-mentioned property for inspection purposm SEE REVERSE FOR EXPLANATORY LANGUAGE `s • -`Signature of Applicant a Agent - - - Date WORKERS COMPENSATION DECLARATION A ► � J`� mal +:lam - -� �i - Tat V'Y +e �I II t _ _ _ _ _ _ _ _ C� hereby affirm certificate have a certificate of consent tone, _ -APPLICATION - FOR BUILDING PE_R_MIT� erf Insure ore copy the of Workers 0 Lob Compensation Insurance, ora certified copy thereof (Sec' 3800 Lab C ) _ COUNTY OF LOS ANGELES BUILDING AND SAFETY I Policy No Company - - - - - -� ❑ Certified copy is hereby furnished t - FOR APPLICANT TO FILL IN auILDINc' �V Certified co a filed with the court building m ec Py IY 9 nP BUILDING0 p ^ . Q/. I I ) 47 tion deportment ADDRESS d �P�A e l..t IIrU Dote, Applicant` r CITY !e 4 CA ZIP J 0 IDfJLLITy 1 CERTIFICATE OF EXEMPTION FROM WORKERS S6x �7o NO OF BLDGS D -' NEAREST COMPENSATION INSURANCE ` , SIZE OF LOT /. NOW ON LOT K/� (,ROSS ST _ I (Thu section need not be completed d the perrnn a for one - -- - CT /�. Y 6 7 &OCK LOT NO - Lo " ~ hundred dollars($100)or leu ) MAP BOOK"' ✓ ` PAGE PARCEL ASSESSOR T OWNER NI GULA4E ,�c�Cy NO _�46 20 115E ZONE 1 I cerhfy�thot in the performance of'the work for which this NO Perim n issued, shall not employ any person in any manner RESS4930 _ -r (� Q�UQ/ _ i SPECIAL, -- -- - - - - - - - - - no as to become subject to the Worke s Co pensotion Laws CONDITIONS .. 07 t ��~�,p.��' _ CIrY_`1 e='- 1e---C` - - zIP_ �t 7d o I 8 Date J Applicant t)- - ' __._ _ __ _ _ _ _ _ _ _ _ - NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT _GROUP TYPE I FIRE SSED BY O Exemption, you should become subject to,the Workers' I = ENGINEER NO C. 1 CONST ZONE- - I 10 Compensation provisions of the Lobor'Code youlmust forth- ADDRESS C. C- �J v_ 3 _ W with comply with such provisions or this permit shall be --- deemed revoked TEL STATISTICAL CLASSIFICATION APT CONDO CONTRACTOR _ _ _ _ _ LICENSED CONTRACTORS DECLARATION -- - - - -- - LIC CLASS NO - DV4 UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Io , (commencing with Section 7000)of Division 3 of the Business and _ _ _ LIC _ SEWER MAP Professions Code and my license a in full force and effect CITY~ - �• - - - VALIDA710N- SO FT !!'' � ' nq OF __ NO OF _ _ _ CHECK l� �r r License Number Lm Clan' SIZE-- TPS STORIES // 'FAMILIES - ONE VALUATION - v ,. ' DESCRIPTION OF WORK �dL]s IF70 NEW - - Contranor Date tt�� ADD I am exempt under Sec - 2 jagGY f"'OO la..S EY1TY1lbeN , ALTER t 3�1 Q 1 A ' B 8P C for this reason _ REPAIR - $'" -- - � ' Date USE OFYes • • • • • LK DEM'OL t 1 EXISTING BII _ _ Signature - APPLICANT TEL ' FINAL ,2 e 1 2 &8 8 ' OWNER BUILDER DECLARATION PRINT NO _ _ _ - DATE .-- _ �`._ , _ -'• : 1 24.8 8 1 hereby affirm that I am exempt from the Contractor s License - a r c- Law for the following reason (Section 7031 5 Business and ADDRESS FINAL ' Professions Code) - ---' - ' — — --' --O '"I :By=- _- - - o-7 3 1 —84 -i BUILDING r63B - 4 -G_ Blf - - 19 as owner of the property or my employee] with ADDRESS _ wages as their sole compensation will do the work and `the structure is not Intended or offered for sale(Section LOCALITY LC ' 704.1 Business and Professions Code) MOVING --- - -- -+` - - TEL -- _ - - _-- - - - T I�as owner of the property, am exclusively contracting CONT with licensed contractors to construct the project (Sec- ADDRESS ' tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY - SET BACK-" YARD I HWY --TOT PROP LINE WIDTH 1 hereb y off em that there is a construction lending agency for FRONTthe performance of the work for which this permit o issued - - - P L - - - - - - - - - - - ' -- - - (Sec 3097;Cry C ) SIDE ' P l Lender s Name _ - - --- - - 8 1, •� f/ 1DM4 Ref N dd _ Lender s Aress . P C F•e f _ _ _ __ __ Perms Fa__ _ J .I certify that I hove rood this application and state that the _ __ _ __ ___ _ _- Isruonce lee - SJ LDMA P2 N -- - - - - - - above information is correct I agree to comply with all County InveahtPtton Fee ll $ ordinances and State jaws relating to building construction . _ _ _ _ _ _ Total Fee-- IX- - -IDMA Perm N - - - - - -- - U and hereby authorize representatives of this County to enter upon th a ve mentioned property for inspection purposes - ^ - _- - _ -_ ___ _ - sC + Q QN�e.Rg.ce�a_ � O7-31 -�y :Q REVEiW FD.EXI'l/1NA70NY LANOUAW S+gnabre of Applicant or Agent - - Dob - - -- - -"-- - - - •--- - - - - - -- - - " - `- - - - ___ ®'