HomeMy Public PortalAbout5202 TEMPLE CITY BLVD_Building__ WORKERS COMPENSATION DECLARATION ,'A
hereby affirm that I haver certificate of cion In, to self APPLICAT16N FOR BUILDING PERMIT list
insure or o certificate of Workers Compensation Insurance
or o certif�iedd cop. reof (Sec 3800 Lab C ) b•
Palic No/ Com COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Certified copy is hereby lurn.shed -l- BUILDING
FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING r Fs. CLt p
lion deportment ADDRESS IQ 1,1 e L-�1 IDI V
of
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_ Dob (4—fig—till Appbcont CITY C C 1 ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS NEAREST
ClMPENSATKN INSURANCE SIZE OF LOT NOW ON L T CROSS ST
(This section need not be completed if the permit is for one TRACT BLOCK l0T ASSESSOR
NO
hundred dollars($100)or less ) MAP BOOK PAGE PARCEL
TEL
I certify that in the performance of the work for which this OWNER h�C h USE ZONE INO
MA
permit is issued I shall not employ any person in any manners�.� SPECIAL
ADDRESS so as to become subject to the Workers Compensation Laws CONDITIONS
Dote Applicant CITY - ZIP 8.
_ NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE By O
Exemption you should become subject to the Workers ENGINEER NO Z
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Compensation provisions of the LabCode you must forth- ADDRESS �Q� �3 {Wa�
with comply with such provisions or this permit shall be a` '
deemed revoked TEL STATISTICAL CLASSIFICATION APT CONDO Z
CONTRACTOR
LICENSED CONTRACTORS DECLARATION V LIC /�( CLAS NO DWELL UNITS_
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I hereby aum that I am licensed under provisions of Chapter 9 ADDRESS I Z NO l q y 3
(commencing with Section 7000)of Division 3 of the Business and fs" LIC SEWER MAP
Professions Code and
�L my license is in full force and effect CITY Fl CLASS VALLDATION
71"I I MK �`JT1 SI FT SO OF NO GF CHECK SK PIG
License Number L¢ Clan - r_ SIZE STORIES y fAMILES ONE
(�- NEW vuuAno
Contract o�Uagd[�Dale t DESCRIPTION OF erMUle U-N
I am exempt under Sec 'JOY- ��r - I� _30ADD
ALTER �
B 8P C for this reason )a •REPAIR
Date
-
Date USE OF
EXISTING BLDG L T)e nL,e DEM«
Signature =pig NTT Nff0 bb(q I FINAL 9
OWNER BUILDER DECLARATION DATE 3- 7 /
I hereby affirm that I am exempt from the Contractor s License , .IIIaL
Law far the following reason (Section 7031 5 Busmen+ and ADDRLa1-`I W� n .D FINAL i
Professions Code) By BUILDING _
ElI as owner of the property or my employees with ADDRESS
wages as their sale compensation will do the work and ��. /r�-9 / Tj GI 121-.7
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the structures intended nded or offered LOCALITY
x4 for sale(Section ITEMS
70Business and Professions Code) MOVING TEL � 1 --
El 1, as owner of the property am exclusively contracting CONTRACTOR NO c
with licensed contractors to construct the protect (sea- TOTAL. 121 _ 35
tion 70" Business and Professions Code) ADDRESS .HECK1 15 CONSTRUCTION LENDING AGENCY SET BACK YARD TO� UNE WIDTH
I hereby-off irm that there is a cunsvuction lending agency for== _- =FRONT =- --- —_ _ __ CHANGE ,O
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C ) - SIDE
P L
lender s Name 111300- 0e1 1�
Il , 7 �^14
DMA Ref M *0351 AM 10:17'
Lender s Address P C Fee f Permit Fw � '
I certify that I have read this application and state that the wvorice Fee d4a LDMA P/C N
above information is correct I agree to comply with all County Invemgotion Fee
$ ordinances and State jaws relating to building construction, Total Fee
Q and here uthorue representotives of this County to enter tDNA Par.
upon the ve mentioned p party for inspection purposes
SEE NEVOW FOR EXPLANATORY LANGUAGE
netare of Applicom or Agent Duro n o