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Home My Public Portal About5102 TEMPLE CITY BLVD_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to ,elf _APPLICATION FOR BUILDING;PERMIT inure, or a certificate of WorkerWorkers' ComCompensation Insurance, - certified copy thereof (Sec 3BD0, Lab C) ,7 ollcv '/ � Company 1014? COUNTY OF LOS ANGELES - BUILDING AND SAFETY olicy NCJ D�C-L Pa y. BUILDING ❑ Certified 'copy is hereby furnished FOR APPLICANT TO FILL IN I ADDRESS 1�1Do1 Certified copy is filed with the county building inspec- - WILDING �� tion department 70 r _/p.-9- / OTY zIP LOCALITY Doe"V-7-!7/ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT _ r CROSS ST 47 COMPENSATION INSURANCE p _ _ np -f t -(This section need not be completed if the peimit is for one - - TRACE 1 BLOCI( LOT NO MAP g� p-,/ _ pq'GE Q/3 pgRCELQ/ hundred dollars ($100) or less ) TEL USE ZONE MAP OWNER ,L G No o�� INO �I certify that in the performance of the work for which this r.permit is Issued, I shall not employ any person in any manner - ADDRESS - CONDITIONS, V OIL so as to become subject to the Worker'Compensation Laws , O - CITY ZIP '. Date Applicant ARCHITECT OR TEL - M DISTRKT GROUP TYPE I PROCESSED BY NOTICE TO APPLICANT If, after making this Certificate of ENGINEER - NO - CONST ZONE Exemption, you should become subject to the,,Workers' o '/ J U Compensation provisions of the Labor Code you must forth- ADDRESS - - r�Q g -{Z .J with comply with such provisions or this permit shall be e L STATISTICAL CLASSIFICATION APT CONDO h deemed revoked I I Al LICENSED CONTRACTORS DECLARATION �C/ LIC CLASS NO DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapterit ADDRESS •' NO (commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP i and Professions Cade and my license is in full force effect CITY 6 CLASS jsK PG VALIDATION SO FT NO OF NO OF CHECK License Number 7 7.7�c�Z Uc Class SIZE STORIES FAMILIES ONE VALUATION ///�•'//yy�// DESCRIPTION OF WORK ,]/A� L NEW ❑ 'Canlrada G DOtlj1��- ❑1 am exempt under Sec L .010 eAW ❑ pop.ALTER B 8P C for this reason '�� REPAIR ❑ fUSE OF - Ik.te - EXISTING BLD,d DE/AOL ❑ Signature APPLICANT (PRIM) / /�C��L`Z CJYC,gb FINAL OWNER-BUILDER DECLARATION DATE Z- I0-7� _ I hereby affirm that I am exempt from the Contractor s License - Low for the following reason (Section 7031 5, Business and � � Professions Code) _ - _ _ NT - ❑ 1, as owner of the property or my employees with AUILDDDRESS • wages as their sole compensation,will do the work and the structure Is not intended or offered for sale(Section LOCALITY ❑ 7044, Business and Professions Code ) MOVING TEL CONTRACTOR TEL 1 as owner of the property,am exclusively contracting with licensed contractor to construct the project (Sec- ADDRESS - - - Ai i.T•T tion 7044, Business and Professions Code ) EI D AC( A , OC FROMEXIST j �7N•-CONSTRUCTION LENDING AGENCY PRO LINE WIDTH I hereby affirm that there is a construction lending agency far FRONT i'�- ` the performance of the work for which this permit is issued P L (Sec 31)97, Civ C > SIDE TIjTAL "}5 _ 98; Lenders Lenders Name IDMA Ref » i-HET K _5-. . PC Fee$ S Perms Fee HANGS Lender's Address C - ,t li 1 I certify that I have read this apphootion and state that the Nuance Fee vl I LDMA PTC R oil above information is correct I agree to comply with all County Inveangaimn Fee ` ordinances and State jaws relating to building construction, Tocol Fe LDMA Perm R 1„Ijl�j}-QI]Qi il]� j,l i and hereby authorize representatives of this County to enter . n u n the ' -rygh on Arty for inspection p C�41S 1 l// ctioAf91U:is SLE REVERSE FOR URLANATORY LANGUAGS Sigonture of oApplicant or Agent Dole WORKERS'COMPENSATION DECLARATION hereby affirm that I hove r certificate of consent to self -APPLICATION- FOR- BUILDING PERMIT insure, or a certificate of Worker Compensation Insurance I - or a (faled copy thereof (Sec 3800, Lab C ) PolR ou '23_1Q2gompany t_FlE0Atju'F INA Co - - - COUNTY OF LOS ANGELES ,, BUILDING AND SAFETY / Certified copy a hereby fumtshed BUILDING ❑ FOR APPLICANT TO FILL IN- - - ADDRESS - O TFM (6 C t L Certified copy Is filed with the county building mspec- BUILDING hon deportment - ADDRESS Q L - LOCALITT. Y ' GG _ NEAREST Date 2'Z`�� Appllm CITY . ZIP CROSS ST ✓ CERTIFICATE OF EXEMPTION ROM WORKERS NO OF BLDGS ASSESSOR COMPENSATION INSURANCESIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed If the permit Is for one TRACT BLOCK X07 NO USE ZONE MAP y _ //_ - \ _ hundred dollars ($100)w less ) - r SPECIE 1_'m/ V I certify that In the performance of the work for which this OWNER 8 —C CONDITIONS a permit Is Issued, I shall not employ any person In any manner - - - - - - DISTRICT GROUP TYPE FIRE PROCESSED BY O so as to become subject to the Workers Compensation Laws ADDRESS CONST Z 'ImV Date Applicant CITY I ZIP STATISTICAL FICATION APT CONDO O NOTICE TO APPLICANT If, after making this Certificate of ZITT R OR rj Exemption, you should become subject to the Workers' NO CIlSS NO DWELL UNITS_ I W Compensation provisions of the Labor Code, you must forth- IL ADD�� ' _ _ - SEWER MAP to with comply with such provisions or this permit shall be - Z deemed revoked comgSbwz erfw" TEL 7 7 BK PG 4 VALIDATION - LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am Licensed under provisions of Chapter 9 ADDRESS24 0 VIEItLt O 9 Q VALUATION (commencing with Section 7000)of Dwiston 3 of the Busmess and A _ Professions Code and my license Is In full force and effect CITY C� 6a' CLASS L 2 o a O4 -L /j/�� (� SO FT NO OF - No OF CHECK , License Number LK Class_L,�n SIZE STORIES FAMILIES ONE Con or Date 2• Z (�SI 4 DESCRIPTION OF WORK V I.Al NEW Els ❑ I am exempt under Sec * - 1.(l ADD ❑ - - - - FINAL B 6P C fat s this reason I _ l 2 ALTER O DATE REPAIR USE OF Date EXISTING BLDG DEMOL ❑ FNA - Signature APPLICANT ly NO n Y OWNER-BUILDER DECLARATION 7 ;F907 6 A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 S Business and (A/ Prof ' �j �5 3 • • • • • ) Professions Cade) ❑ 1, as owner of the property or my employees with B - - 2 • • 49 88 wages m their sole compensation will do the work and . 49 8 8 the structure n not Intended or offered for sale(Section LOCALITY 7044, Buslnew and Professions Code) MOVING TEL ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO 0 2 2 1 - 84 with licensed contractors to construct the project (Sec- , tion 41 70Business and Professions Code) ' REQUIRED TOTAL SETBACK FROM EXI CONSTRUCTION (ENDING AGENCY SET BACK YARD HWY PROP UN WIDTH , I hereby affirm that there n a construction which t is per agency fat FROM - the performance of the work fat which this permit a Issued P L f Sec 3097, Civ C ) SIDE AP L Lender s Name lNsLA� ' P C Fee$ v Permit Fee ^ Leader!AddressI I certify that I have read this application and state that the Issuance Fee above mfoanarlon Is correct I ogres to comply with all County Inve ligation Fee ' ordinances and State jaws relating to building construction, Toal Fee and hereby authorize representatives of this County to enter upo above-meat property fat inspection purposes - - d2-21-61 1 - La IevHnE FOCI EXPLANATORY LANGUAGE _ S graNre of IcaN w Agent Date X�