HomeMy Public PortalAbout5324 TEMPLE CITY BLVD_Building__ WORKERS CLOALPENcVATION DECLARATION
hereby affirm that I have r Comson
cene of consent to APPLICATION FOR BUILDING PERMIT
Insure, or a certificate of Workers'Compensation Insurance ce
or a certified copy thereof�(Sac 3800 la C ) "
Policyd6UQ&i &&pony COUNTY OF l05 ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDBUILRESS J
141 Certified copy is filed with the county building mspec BUILDING /) -
L/T tion department ADDItF55 C.
Dote Applicant 2EZIP 2 LOCALITY
RTIF TE OF EXEMPTION FROM WORKERS' NO OF BUMS BEST
i COMPENSATION INSURANCE SIZE OF LOT NOW ST
(This section need not be completed if the permit n for one _ _ TRACT ____ - � _• a LOT NO - - --- ASSESSOR
MAP EOpC- -- - PAGE PARCEL
hundred dollars ($100)-or lou )
TEL ZONE
I certify that in the performance of the work for which this OWNS NO NO
permit Is issued I shall not employ any person In any mannerSPEOAL
so as to become subject to the Workers'Compensation Laws 'ARES CONDITIONS O
Date Applicant CRV ZIP U
NOTICE TO APPLICANT If after making this Certificate of ARC IJffR OR Taj Lp DIWICT P TYPE FI D BY
Exemption you should become subject to the Workers' ENG ��T W1I�J-!'2) CONST '/ Z C.)
Compensation provisions of the Labor Code you must forth y�pg� `�1 "`�' • � a
with comply with such provisions or this permit shall be �� — "— STATISTICAL CL SSIF TION APT NDO Z
deemed revoked
LICENSED CONTRACTORS DECLARATION C e LK CLASS NO -' DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS J
(commencing with Section 7000)of Division 3 of the Business and U SEWER
Professions Code and my license is in full force and affect CITY - -PG f'L/ VALIDATION
SO FT NO OF NO OF CHECK
LIC Nu r I Clain SIZE STORIES FAMILIES ONE VALUATIONO��v
Cont JL7 Date DE SCRIPTION OF WORK NEW ><
Qi ADD
I am exempt under Sec
ALTER
B&P C for this reason _ G REPAIR s 2 8 9 6 7 A
Date USE OF
EKI TING BLDGSIER
DEMOI • • •ie,e
APPLICANT LTi
Signature
DECLARATION PRINT — NO G _ CJ/1 1 - - 488
ffaATT
ADD
1 hereby off that I am exempt from the Contractor s License S e. 1 D s s e /.1 9.8 8 5Low for the following reason (Section 7031 S, Business and RESS J 1
^Professions Code) - - PRE5ENT0213-88
I as owner of the property or my employees with
BUILDING
p LRDRESSS+ +
wages as their sole compensation,will do the work and LOCALITY +
the structure a not intended or offered for sale(Section '
7044 Business and Professions Code) MOVING TEL PV '
M1, as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec- - I
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCYTOTAL TBACK BACK YARD HWY UNE WIDTH
I hereby affirm that there no construction lending agency for FRONT
the performance of the work for which this permit is issued P
(Sac 3097 Civ C ) SIDE
PL
Lenders Name _
IDMA Ref Y
8 P C Fee S
Permit fes
Larder's Address ,
I certify that I have read this application and state that the Issuance Fee S LDMA P/C Y ,
above information is correct I ogres,to comply with all Court
a8r PY N Investigation Fee
ordinances and State laws relating to budding construction Tool Fee TDMA Perm If 1
L
and hereby outhouse representatives of thisCounty ro enNr
n the hove-mentioned proper for inspection purposes ,
/L t
.>M .7- I�D M REVEM FOR IMPLANATORY LANOUAGE
Sigrroture of App rant or Agent Data