HomeMy Public PortalAbout5008 TEMPLE CITY BLVD_Building__ WORKERS' COMPENSATION DECLARATION - ^
sure, o affirm that I haver certificate of consent to ;elf APPLICATION FOR BUILDING PERMIT ryGII I''S
'?sure, or a certificate of Worker Compenso�h'on��hnwra�nc�e, _..
or a y N4rf copy thereof (Sec 3800, Lab C,— C*. 4 l COUNTY OF LOS ANGELES .BUILDING AND SAFETY
Polity NoQComponyLU
Du Certified copy is hereby furnished FOR-9'j- FOR APPLICANT TO FILL IN - ADDRESS
❑ Certified copy is filed with the county building iBUILDING
tion department r4pet ADDRESS
r i . CITY C �\ ZIP 1 LOC4LITY
Date Applicant NO OF BLDGS t NEAREST `
CE TIFICATE OF EXEMPTIOIQ FROM WORKERS SIZE OF LOT - NOW ON LOT 1 CROSS ST
COMPENSATION INSURANCE - ASSESSOR
(This section need not be completed if the permit is fw one TRACT BLOCK LOT NO MAP BOOK PAGE` PARCEL
hundred dollars ($100) or less ) iEt
OWNER G Qo IJO - USE ZONE INO
MAP ,
I certify that in the performance of the work for which this - SPECIAL Y
permit is issued, I shall not employ any person in any manner ADDRESS S ai � CONDITIONS a-
so as to become subject to the Worker Co�pensatt n Lawa Q
clry ' ZIP ARCJ�
V
Date APiJ: Applicant ENGIN ER OR TEL DISTRI GROUP TYPE FIRE PROCESSED BY Q
NOTICE T APPLICANT If, after kmg this Certificate of ENGINEER _ NO
Exemption, you should become bject to the Worker CONST ZONE ,
•, Compensation provisions of the Labor Code, you must forth- ADDRESS vii 3
with comply with such provisionsor this permit shall be TEL Z
STATISTICAL CLASSIFICATION APT CONDO
`I deemed revoked CONTRAROR 2y �'/
LICENSED CONTRACTORS DECLARATION uC CLASS NO DWELL UNITS_
7 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O (rL4 NO
commencing with Section 7DOO)of Division 3 of the Business \\ LIC SEWER MAP '
dad Profeuwns Code and my license is in full force and effect CITY 0. q cit CLASS C-5 G p�d VALIDATION
SO FT NO OF NO OF CHECK BK
License Number SSIH'SIS� Lic Class CSCi I STORIES FAMILIES ONE
(`, DESCRIPTION OF WORK c, NEW ❑ VALUATION ,
Con'tractorTtx+'trthF WT Dote 2 4f - ,
_ !( s / ►
El Cam exempt under Sec LJ APO
3 ` b AW
ALTER_❑
B 8P C for this reason
USE&t%
REPAIR ❑ $
_ - hate EXISTING BLDG e'rIi ( r - - DEMOL ❑
Signature APPLICANT _TEL_ _ FINAL _/ q
OWNER-BUILDER DECLARATION (PRINT) NO DATE
I hereby affirm that I am exempt from the Contractors License _ _
Law for the following reason (Section 7031 5, Business and ADDRESS FINAL 1
Professions Code) OM� BY
❑ I, as owner of the property, or my employees with BADDRESS
UILDING ni_�"T.'T
wages as their sole compensation,will do the work and - `07 - 5'
the structure is not intended or offered for sale(Section LOCALITY - 55 J'�•7
7044 Business and Professions Code ) — - MOVING _ TEL 1 ITEM:
withas owner of the property, am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec- ADDRESS - - - - - - - - TOTAL 58 - 75
tion 7044, Business and Professions Code )
CONSTRUCTION LENDING AGENCY SET eaRED YARD Invv AL FRa''' - - ll'{El V i
I hereby affirm that there iso construction lending agency for FRONT C HANGS
the performance of the work for which this permit a issued P L - - --
(Sec 3097, Civ C ) SIDE
P L 00170-1]001 2111, >1
Lender's Nome '
tDNA Ref Y cc-y� {
Lendm s Address PC Feet Permit Fee �� JJUL 1 rR 111;t(r
2
g I certify that I have read this application and state that the Issuance Fee LONA P/C Y
above information is correct I agree to comply with all County Investigation Fee /J
ordinances and State laws relating to building construction Total Fee r/ LDM4 Perm N
and hereby author.. rep senI I of this County to enter _ 1
upon a abo,b7-rr�ntion property or inspectiO4 ioon/puru�r/j�'pJ/-sseess
A _NI/ / _ $EE REVERN FOR EXPLANATORY LANGUAGE
Signature of Appl¢ant or Agent