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Home My Public Portal About5722 A-E TEMPLE CITY BLVD_Building__ t ' WORKERS COMPENSATION DECLARATION " hereby off irmw that l Jwve ccertificatee of cansen, to self APPLICATION FOR BUILDING PERMIT Insane or a nrflcote'of Worr Com kers Compensr�tlon Insurance or of eftift;,d copy thetkof (Sec x,800 Lab.C ) COUNTY OF LOS ANGELES BUILDING AN4 S FETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING �1 AM /c. netA -- BUILDING copy o filed with the county building mspec BUILDING ��2� �� ' c hon depOnmenf ADDRESS Lir Dote Apphcont CITY7EMECZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERSNO OF BLDGS NIEARES7 COMPENSATION INSURANCE SIZE Of l07 /10,450-5 S IVOW ON LOi ST (This section need not be completed if the permit is for one TRACT 56 BLOCK LOT NO ASSESSOR hundred dollars(SIOD)or less ) MAP BOOK PAGE PARCEL TEL � USE E MAP I cendy that In the performance of the work for which this OWNER O a NO NO permit Is Issued I sholl not employ any person in any manner ADDRESS CJ1 W S&-r#i •5'•f- SPECIAL ^4 t so as to become subject to the Workers Compensation Lows COFDI IONS O Date Applicant CITY Qf Cha ZIP G fY NOTICE TO APPLICANT If after making this Certificate Of ARCHITECT OR fG j pTEj Lp DISTRICT GiKK1P TYPE HRE SSED BY 0 Exemption, you should become subject to the Workers �j CONST Z Compensation provisions of the Labor Code you must forth ADDRESS 7523Frail Ve �� — d with comply with such provisions or this permit shall be deemed revoked CONTRACTOR fl ar / STATISTICAL MSSIF TON APT DO Z LICENSED CONTRACTORS DECLARATION T LIC MSS NO DWELL UNITS- 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRESS I e. L (commencing with Section 7ODD)of Division 3 of the Business and LIC SEWER MAP Professions Code and my license is in full force and effect CITY CLASS PG,/ 6 50 R NO OF NO Of CHECKBIK VALIDATION License Number LIc Class SIZE �/� STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK NEW Connector Date t, Ago 'Q 0 21.8 8 A 0 1 am exempt under Sec _ " ` p ALTER # e e e e 23 B dP C for this reason o! REPAIR i 1 - 751.62 Dote EXISTING BLDG DEMOL e e 7 5 1.6 2 5 Signature APPUIC LT TEL $ $ FINAL p OWNER-BUILDER DECLARATION PRIM Q L 1 �� 7 1 B-88 1 hereby offum that 1 am exempt from the Contractor s License �I Low for the following reason (Section 7031 5 Business and ADDRESS FINAL g Professions Code) BI' [� QI as owner of the property or my employees with BUILDINGADDRESS wagm as their sole compensohon will do the work and LOCALITY , the structure Is not Intended or offered for sale(Section 70" Business and Professions Code) MOVING TEL L F1 1 os owner of the property, am exclusively contracting CCiNTRAROR /5 '�� I " with licensed contractors to construct the project (Sec- ADDRESS O� `F� y. S� �LoI tion 70bf, Business and Professions Code) t CONSTRUCTION LENDING AGENCY SET BACK YARD HWY T PROP LINE WIDTH SETBACK FRC'VF EXIST I hereby offum that there is o construction lending agency for FRONT \ the performance of the work for which this permit is Issued P 1. (Sec 3097, Civ C ) SIDE PL Lender s NameiDMA $ P C fee f It P. 11 Fee ,�j Ref E Lender s Address n445: pop. ` i I certify that 1 have read this application and state thoi the fi O Issuance Fee I LDMA P/C• above mformotlos correct I agree to comply with all County Invest g hon FN (/� - ) ordw lnotxes and State kas relating to building construction, Total F« / L` LLS IAMA Perm 1 and hereby authorize representallves of this County to enter uPon the obove-mentioned property for Inspection purposes sH R!VMU FOR EIL/L I NATORY LANOUAOE - SpmNre of Applicant Or Agent Date