HomeMy Public PortalAbout5472 TEMPLE CITY BLVD_Building__ WORKERS,COMPENSATION DECLARATION
hereby affirm that I have r certificate of tion Int to ,elf APPLICATION FOR BUILDING PERMIT
insure, or a cenrficate of Worker Compensation Insurance, � BUILDING ,
PERMIT
a certQqy the
f1g'dreof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY "
/7' b—v7b-�S f
Policy No 576710 �"p mpony _
BUILDING
�❑�77 Certified copy a hereby furnished FOR APPLICANT TO FILL IN ADDRESS
19 , Certified copy is filed with the county building inspec- &JILDINO
tion department '°� EM C L'
/ V CITY M C ZIP 7 g0
Date l�6'�6 Applicant !'� /� LOCALITY
NO O CROSSSS - -CERTIFICATE OF EJ(FAIPTION FROM WORKERS � SIZE OF-LOT NOW ON LOT � t CROSS�
COMPENSATION INSURANCE ASSESSOR -
(This section need not be completed if the permit is for one TRACE "" - &OCK ^_- LOT NO - - _ MAP BOOK V - PAGE PARCEL
hundred dollars ($100)or less ) ' s�� TEL gy -
' OWNER lLLJ vsyVC fJ — NO 8' NO
USE ZONE MAP
I certify that in the performance of the work for which this SPECIALe M _ O• a
permit is issued, I shall not employ any person In any manner- ADDRESS _rZ" C 4- CONDITIONS „/ O
so as to become wblect to the Workers' Compensation Laws /78U i V
CITY ZIP 7
Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE BV
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO CO ZONE - O
Exemption, you Ag should become subject to the Worker'
i Compensation provisions of the Labor Code, you must forth- ADDRESS V pg&('I a t
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION _ , APT I CO Z
deemed revoked I CONTRACTOR 1;941-NO '24F ,
LICENSED CONTRACTORS DECLARATION uC CLASSNoDWELL uNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .3 A' 4e/ f /)I'NO `) aZ SEWER MAP
(commencing with Section 7000)of Division 3 of the BusinessLIC .
and Professions Code,and my license is in full force and effect CITY Ery CC 1 CLASS G BK PG VALIDATION
�q 50 FT NO OF NO OF CHECK
License Number. '162$5-.2!Lic
'Cl.,Cjau SL SIZE STORIES FAMILIES ONE
VALUATION ,
Contractor. 22"6 /`�/�pote b/�9G DESCRIPTION OF WORK � S o2
-ow
❑
AID O
I am exempt under Sec - C=-7L�O k 'IL L7� T/^'�
ALTER ❑
B 8P C for this reason c7, a Z .4 R gS REPAIRUSE OF-
❑ S. - {
Date EXISTING BLDG OFMOL ❑ '
Signature - APPLICANT -EL - FINAL
OWNER-BUILDER DECLARATION (PRINT) NO i
I hereby affirm that I am exempt from the Contractor s License - - DATE
Law for the following reason (Section 7031 5, Business and ADDRESS FINAL nr
Professions Code) - PRESENT -- - - By It '" ACCT.i
❑ I, as owner of the property or my employees withDIN � t 33� _ " ]�j�y�
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY , i t 1 ITEM '
7044 Business and Professions Code ) i` MOVING - - - - TEL - - - - -
❑ I as owner of the property, am exclusively contracting CONTRACTOR NO _ TOTAL 125 .55
with licensed controctor to construct the project (Sec- ' - ADDRESS
tion 7044 Business and Professions Code ) Of CK
u�
7
CONSTRUCTION LENDING AGENCY gAYARD Hwy AL P aEFROM EXIST
WIDTH - - CWGE , .00
I hereby affirm that there is a construction lending agency for - FROM _
the performance of the work for'which this permit is issued P L
(Sec 3097 CivC ) SIDE
PL - - LRf
�Ol 6/17/96
Lenders Nome2 6938 1 AM 8:22
PC Fee S Porma Fee Lender's Address I certify that I have reod-this application and state that the Issuance Poe above information n correct I agree to comply with all County Invmnpotion Feeordinances and State jaws relating to bmldtng construction, Toml Fee .7•'3 qgz
` 9�ht_hz representatives of this County to enter Ined property for inspection purposes
6 s SEE REVERN FOR EXPLANATORY LANGUAGE _
Signat aApplicant or Agent Date