HomeMy Public PortalAbout4841 TEMPLE CITY BLVD_Building__ n
WORKERS COMPENSATION DECLARATION
hereby affirm crtthat have a certificate of garment to self APPLICATION FOR BUILDING PERMIT,
insure or a certificate d ficate of Workers Compenanon Insurance or
a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
gf;I,c n12-'106 party Argonaut
Certified copy Is hereby furnishedbUIWING
AD ADDRESS 4841 Tem le Cit B1.
FOR APPLICANT TO FILL IN
Certified copy ii filed with the county building inspec BUILDING
113Js tion department ADDRESS 4841 Temple, Cit B1. LOCALITY Temple C1
Date 11-1-83 ApplicccH. L-. RandolCo. In O v zIP N sESTT
'CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR ,
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one _ USE ZONE MAP
hundred dollars ($100)or less ) TRACT BLOCK LOT NO NO - ! r
TEL SPECIAL O
I certify that in the performance of the work for which this OWNER F a k Pfe er NO 286-1388 CONDITIONS
EL
is issued I shall not employ any person in any manner DISTRICTij GROUP TYPE FIRE PROCESSED BY U
+ so as to become subject to the Workers Compensation Laws ADDRESS 48411 Temple Cit B1. CONST ZONE 0L
r / O
Datel-11 -81 Apphcant H T, RamAnl rO. TARCHITECiOR ZIP TEL Ti TI C1A551FCATION APT CCxJDO W
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CLASS NO DWELL UNITS_ d
Exemption you should become subject to the Workers y
Compensation provisions of the Labor Code you must forth- ADDRESS MMMSEWER MAP =
with comply with such provisions or this permit sholl LIR
deemed revoked I i CONTRACTORH 1 CONO 288-4040 BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION I LIC
I hereby off irm that I am licensed under provisions of Chapter 9 ADDRESS NO 186086 VALUATION
(commencing with Section 7000)of Division 3 of the Business and UC
i Professions Code and my license is in full force and effect CITY _ CLASS 52216 . 00
I
186086 C-39 SOE
License Number. Lic Class
ET STORIOLIES CHECK
'
Contractor• L. Rdnd01 C@w, 1-11-83 DESCRIPTION OF WORK Tear off exists S❑ ,
1 am exempt from the licensing requirements as I am o tile, Re—roof With COMPO
m O ADD ❑
licensed architect or a registered professional engineer ALTER ❑ FINAL
acting' in my professional capacity (Section 7051 1 s 12x18 & flat areikEPAIR DATE
Business and Professions Code) USE OFTT�sT�� }}}}��
EXISTINGBEDG� 3 Ply Fiberglas DEMOL ,❑ FIN
Lic w Reg No Dote APPLICANT r TEL By
OWNER-BUILDER DECLARATION PRINT NO 288-4040
I hereby affirm that I am exempt from the Contractor's License gDDRE55 52 11e Bl San Gab.
Law for the following reason (Section 7031 5 Business and
Professions Code) �9 9 0 0 9 A
BUILDING
ADDRESS - # • . • . • 1
as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and r
the structure is not intended or offered for sale(Section LOCALITY I - 5925
7044 Business and Professions Code) - MOVING - TEL
1 as owner of the property, am exclusively contracting CONTRACTOR NO • • 5 9 2 5 Lm
with licensed contractors to construct the project (Sec ADDRESS
bon 7044 Business and Professions Code) - , 12-83
REWIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP UNE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
ihe�performance of the work for which this permit is issued P L
(5ec 3097 C v C ) SIDE
PL I
Lenders Name
Lender s Address P C Fee S Permit Fee
L I certify that I have read this application and state that the Issuance Fee
above information is correct I agree to comply with all County lovesngaoon Fee
` ordinances and State laws relating to budding construction Toml Fee
and hereby authorize representottves of this County to enter
U upgn the above mentioned property for inspection purposes 99
SEE REVERSE FOR EXPLANATORY LANGUAGE 1
Sgn.wre of Applicant or Agent Dote ms