HomeMy Public PortalAbout5629-1/2-5631-5631 1/2 TEMPLE CITY BLVD_Building__ . APPLICATION FOR BUILDING PERMIT �]
COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IRI BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self Insure BUILDING ADORESS
' a a certificate of Workers Compensation Insurance or a certified
copy thereof (Sec 3800 Lab C) CITY DP
LOCALRV
Polx:y No ,' JI J 4� Company SIZE 15F LOT r NO OF BLOCS NOW ON LOT
❑ Certified copy is hereby furnished NEAREST CROSS ST
❑ Certified copy is filed with the county building Inspection TRAGT BLOCK LOT NO
department USE ZONE MAP NO
Date Applicant ASSESSOR MPP BOOK PAGE PARCEL ,
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNERF TEL NO TES
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL?
NO
(This Section need not be completed A the permit is for ADORES$one hundred DISTRICT GROUP TYPE CONST FAiE ZONE a�EDBY
dollars ($100)or less)
CITU LP J _I/IFP
—
I certify that In the performance of the work for which this permit V 3
IS become
I shall o t employ any parson in any manner 90 83 t0 GHITECi ENGINE L N
become subject t0 itis Workers COITIpeI1581Kx1 Laws GF
STATIS TICALC IF] MIN APT CONDO
Data Applicant �- ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT If after making this nAlcate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you should became Subject to the Parkers CONTRACTOR q/ TEL NO SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code you must forthwith v
compty,with such provisKms or this permit shall be deemed revokedFRONT
• PL
LICENSED CONTRACTORS DECLARATIONSIDE
CITY ♦ UCCUSS04i PL
x
I hereby affirm that I am li nsed underprovmio s of Chapter 9 SEWER MAp 1
(comment g with Section 7000)of Division 3 Of the Business and SO FT SIZL NO S O OF FAMILIES
Professor Code and my license s In full force and effect NEW -EK PG oil. d
DESCRIPTION OF WORK ("T
License Number Lit Class ,�? � 00' / ADD ❑ vuunnoN VC
Con[rector igl �._,/7 9'� ALTER ❑ $ �— cc
❑ I am exempt //�y �J L REPAIR ❑ $ 0
under Sec
BSPC for this reason 4 7 sg EMOL ❑
�/ Date USE EXISTING M ❑ LDMA P/C♦ _ 1 a
Signature 4�E 0: 'i, AP0.0 ofigPLICANT IPfd>!T) TEL NO LDMA Perm. AGCT.T Z
❑ I as owner of the property W my employees with wages as =
their sole compersatpn will do the work and the structure Is ADDRESS F `7`767 164-85rot Intended or offered for sale (Section 7044 Business and FINAL DATE a 1 ITEMS
Professions Code) WLL THE APPJCMT OR FUTURE wiUYNO OGCLPANT HANDLE A HAZARDOUS MATERUL
❑ I as owner of the property am exciuwaly contracbrg with OR A MIXMiE CANTANLNG A HAZAACOUS MATERI I ECWL TO OR GREATER THAN TrE _ Q TOTAL 164. 85
licensed Contractors to Construct the project (Section 7044 ANKn1HTS SPECFl ON THE HAZAAD0119 MATERWL9 RFORMATKIN GUOEi FINAL BY > /'y (� p�
Business and Professions Code) YES❑ NO CHECK 164.81
ANLL THE NTENDED USE CF THE BUIXING aY THE AP0.1LM'i OR FUiLP+E BULRN3 �{j����� .'M
OCCUPANT REOURE A PERMT FOR CWsiRLGTKllI OR MODIFICATION FROM THE SOUTH 41L9NG 00
CONSTRUCTION LENDING AGENCY cGasr AIR WAury MANAGEMENT asrRcr IscAGMOI SEE PSRGUIDEIJNE& .rnmNG uECKusT FOR
1 hereby affirm that there IS a corstnuctlon lending agency for YES❑ No i m
w the performance of the work for which this permit Is*sued(Sec (�i''Iiyly
3097 CIV C) WAVE READ TIEHAZAPLDUSMATEfiA13.ffQTAATIONGUIDEANDTIESCAANDPERMiTNG ' vJ� GOOD-0001 3/18/93
CHECKLIST 1 UNDERSTAND MY REWIREMENTS LACER THE LOS ANGELES COUNTY CODE
Lenders Name Ni�lawa d -y zZ40 MATETE�FE°iEPwrT2v2gD SECTIONSFORoerwnpG A PERI FROM TH`E°SCAGMo"G HAS R°OUS
8749 1 AM 9*8
Lenders Address >
I certify that I have read this application and state under penalty - A
g Of penury that the above Information is correct I agree to comply PC FEE PERMIT FEE r
�. vnth all county ordinances and State laws relating to bulldog ,
consmIctlon and hereby authorize representatives of this County ISSUANCE FEE
m to enter Lyon the above-mentioned property for inspection purposes
INVESTIGATION FEE TOTAL FEE /
SEE REVERSE FOR EXPLANATORY LANGUAGE ��