HomeMy Public PortalAbout5126 TEMPLE CITY BLVD_Building__ APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES % BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL'14.K BUILDING ADDRESS
Wo
I hereby efhrm that I have a cendicate of consent to self .cure BUI rrG ADD SS G
or a certificate of Workers Compensation Insurance or a cerhfed
copy Ther B00 b C) CITY zm
Policy No Company --71F," LOCALIT
SIZE OF LOT I Q NO OF BLDOS ON LOT
❑ Certified copy a hereby furnished / NEAREST CROSS ST
❑ Cartlfled copy a filed with county building Inspection TRA BLOCK— LOT NO y
depa2.�/tme—nt'-��__ 3 _ _ ___ _ _ _ __
J/�� �f "�"1 USE ZONE P
Defe—, ^� I Apolpant _ _ _ _ - ASSESSOR P BOOK RAGE PPAGEL _--/ 013oZ ,C `/ _ GDNDIT,DNS
CERTIFICATE OF EXEMPTION FROM WORKERS OMER L
COMPENSATION INSURANCE 1 WITHIN 1000 FT OF SCHOOL' VES NO
(The section need not be completed If the permit 6 for One hundred ADDRESS ��•/r DISTRICT 7;)p-
P TYPE CONST FIRE ZONE PROCESSED BY
dollars IS 100) or less) - * ,...air
1 Certify that m the performance of the work for which this permit CITY Zlp� pIs Issued I shall rot employ arty person In any manner so as to QO q
became subfed to the Workers Compensation Laws ARCHITECT ORE INEER TEL NO
STATISTICAL CL�SIFlCATION APT CONDO
Date Applicant
ADDRESS CLASS NO �0((� DWELL UNITS
NOTICE TO APPLICANT If after making this Certificate OfNEOUIRED TOTAL SETBACK FROM EXIST
EXemptpn you ehOUld became subject to the WorkersCO TE NO
Conversation provl9rone Of the Labor Code you must forthwith / SET BACK YARD HWV PROP LINE V4DTH
FRONT
comply with such aweDra or the permit shall be deemed revoked AGDRE�sC n, NO p L
O 0 SIDE
LICENSED CONTRACTORS DECLARATION Icm / O uc Ctnss P L
I hereby affirm that I am licensed underprwmpns of Chapter 915 L ,A,Egp
(Cannenang with$fCtaOn 7000)of DNspn 3 of the BU9I1BS9 and SO ^ENO OF STORIES NO OF FAMRJES �—H
Professions Cade and I se Is In ull force and t t NEW BK PG , a
License Number Class DE IPT10N OF WORK (�D VALUATON EL
Contracts I Date ALTER Cl 60 U
cc
I em exempt under Sec $ �
OAJF— MIR 0 REPAIR ❑ O
❑
BEPC for the reason ^ N A 8 GAOL ❑ LbP/C U.I
(�" Date + + OF EXISTI 2`' a-
BLDG r _+ ` 11RM O ( ' -
r 1.
Sgnffiure APPLICANT(PHNTI \ TEL NO t - LOW Perm♦ + 1 rk(T.T Z
❑ as owner of the property or my employees with wages as - - I n a 11 F ZO 13
their sole Compensation well do the work and the structure Is ADDRESS - Y - •� .
not Intended or Offered for sale (Section 7044 Business and '\' "li v X15 FINAL DATE Q 1
Professions Code) w+11 THE A➢RILANI OR FUTURE BUILDN occurrNr HANDLE A HAZIA COUS MATERIAL a
❑ I ole Owner of the property am exclum OR A MpmgE CO"mNNG A lIA2A S MATERIAL EIXNL TO OR GREATER THAN THE 1 = ACGT•T
NBIy COntIaCSlfg With AwIX 8f,x"ED ON THE W ARDOUS MATEFAl INFORMATION GUDE, FINAL BY �j
licensed Contractors to construct the project (Section 7044 r - T A' c —.
Business and Professions Code) Yes❑ No❑ 1' 'I i 1(v 'v+ + v j _ j,�Q] " 656.24
WILL THE MENDED USE ori THE SLIMING BY T1E A C,wT OR ENURE BIIM1DNG
OCCLWNT REWIRE A PERMn FOR CONSTRUCTION OR MODIFC RON FROM THE Sp UT II I '1' 1 ..\ ' -1 ) 2 1 1 LI S
CONSTRUCTION LENDING AGENCY COAST AR o TY MANACEMDl1 DISTRICT Sammi SEE PERMnTINo CHECKLIST FOR `
SUES TOTAL 706- 74
1 hereby affirm that there Is a construction lending agency for Yes Ne❑
,N the performance of the work for which the permit Is saved(Sec CHE�v ]D6.74
m HIVE REAOTE IMZARWU$MATEAN$PFCiANPCN GLOE N1l TE eCAG1.0PERMTTWG
N `3097 Cry C') CHECKLIST I UCERSTAlD MY REMREI.ENTS UNDER THE-OS ANGELES COUNTY CODE �(+{{1I��A����(('�'�''
20 100 TutROUGH 2 20 140 CONCER1,11W
Landers Name MATER Y-3 REPOITIM AND FOR CHAPTER 2 20 SECT�S VOBGNNa A PERMIT FROM SCAOMD tMLNDaG _ AOT Off .130
Lenders Address
a w..cR re ram
I cerhty that I have read the application and state under penalty 000ID-0001 41 6/93
$ of perjury that the above Information a correct I agree to Comply PC FEEr /O PERMIT FEE
relating all county ordinances and State laws relatito building JE �i30 9081 1 AM11-42C
construction and hereby authonze represenu try of the County ISSUANCE FEE
to enter upon the above mentioned property fa inspection purposes
m INVESTIGATION FEE TOTAL FEE
eor,.a rw.v Ar. ra_
SEE REVERSE FOR EXPLANATORY LANGUAGE