HomeMy Public PortalAbout4903 TEMPLE CITY BLVD_Building__ WORKERS'COMPENSATION DECLARATION -
hereby affirm that I have a certificate of consent to self APPLICATION FOR 'BUILDING PERMIT ,
insure or a cenWorkers
ificafe of CompensationionInsurance,
or o certified copy thereof (Sec 3800, Lab C ) - COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Policy No It1gLUI Company BUILDING
AppllExc
12
Certified copy is hereby furnished FOR APPLICANT TO FILL IN Q S
Certified copy is filed with the county budding inspec BUILDING nil-r4 I
lion department -y` ADDRESS
Date d...Apphcora CITY ZIP LOCALm
i�=ei
CERTIFICATE OF EXEMPTION FROM WORKERS - - OF BLDGS NEAREST
COMPENSATION INSURANCE' 0 SIZE OF LOT ON LOT OSS ST
_(This section need not be completed if the permit is for one - _- _ _ _ _ ASSESSOR -
hundred dollars ($100)or less ) TRACI BLOCK L7O7EETLl NO - p MAP BOO( I PAGE 1 PARCEL
I certify that in the performance of the work for which this OWNERP1Q> Sto E MAP
NO i
permit n Issued, I shall not employ any person in any manner SPECIAL
ADDRESS so as to become subject to the Workers Compensation Laws CONDITIONS i
Date Applicant ` CITY ARCHITECT ZIP TEL NOTICE TO APPLICANT If, cher making this Certificate of DISTRICT GROUP TYPE FIRE PROLE D BY
Exemption you should become subject to the Workers WEER NO /T� ro� / ZONE
Compensation provisions of the Labor Code, you must forth- i f�yn/ V/ f
with comply with such provisions or this permit shall be ADDRESS r, U
deemed revoked TEL 12
_ STATISTICAL CLAS F TION APT DO fn
CONTRACT �/. Z
LICENSED CONTRACTORS DECLARATION IC CLASS NO !� DWELL UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDR40tJ 9 S44,GVLrIttl
(commencing with Section 7000)of Division 3 of the B mess and `c /� SEWE
Professions Code, and my license is in full force and effect Cm l`C CLASS C- -�
Qp'��s/,.•'.y,�Q /'1 SQ FT NO OF NO OF CHE PG VALIDATION
License Number�O'r'VaLlcCla�sa_S_gr (s�6 SIZE STORIES FAMILIES ONE
.�.JIC6�7d.'1 II x � _ NEW iAWA ON _ —^
Contract DESCRIPTION OF WORK 6�/l/Jl
�— ADD ,
I am exempt under Sat
ALTER
B dP C for this reason - $
REPAIR
Date USE OF
EXISTING BLDG DEMOL
Signature APR /• TEL FINAL� -
OWNER-BUILDER DECLARATION PRIM l
I hereby offum that I am exempt from the Contractor's License
Low for the following reason (Section 7031 S Business and ADMSS fl
Professions Code)
I as owner of thero Y employees BUILDING _
p party, or m em to ees with ADDRESS
wages ct f(heir sole compensation,will o the work and '
the structure is not intended or offered for sale(Section LOCALITY
7041, Business and Professions Code) MOVIE TEL
I, as owner of the property, am exclusively contracting 0 5 2 5 A
41
with licensed contractors to construct the project (Set ADDRESSADDRESSCK SETBACK FROM EXIST # , i
tion 70 , Business and Professions Code) e e e e e
CONSTRUCTION LENDING AGENCY IYARD HWYTOTALROP LIPS WIDTH
I hereby affirm that there is a construction lending agency for FRONT I " 5925
the performance of the work for which this permit is issued P L 5 9 2 5 FS
(Sec'3097 Civ C ) Lor e • e
PL
Lerder s Name
S LDMA Ref It
Lender s Address P C Fees Permit Fee /�s. loop. 0 9 2 5—8 8
v
I certify that I have read this application and state that the laonce Fee 1V �Q LDMA P/C E
above Information is correct I ogres to comply with all County Investigation Fee
8 ordinances and Sate laws relating to budding construction, Total Fee .7-5 TDMA Perrin 1 r
R and hereby authorizer eeenI twee of this County to enter
upon thabov enti property for inspection purposes - -
ri01
ay M KV! FOR EXPLANATORY LANGUAGE
omre of Appl¢on Agent ^ pate