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HomeMy Public PortalAbout5826 TEMPLE CITY BLVD_Building__ ,d' WORKERS'COMPENSATION DECLARATION i I.hereby affirm that I hove�'nWorkers' ' certificate of consent to Self A P P L 1 CAT 1 O N FOR. BUILDING. PERMIT � sure, or a certificate of Worrkk ers'Compensation Insurance, , or a certified copy'tliereof(Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING:AND SAFETY Poltcy,No. Company. BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS tS T ❑ ' 'Certified copy is filed with the county building inspec- BUILDING, ' _ ; tion department. ADDRESS C� L'-. Date4:%-15_f7' Applica - ' i CIT1= ZIP LOCALITY ' CERTIFICATE OF EXEMPTIO FROM WORKERS' N OF BLDGS. = NEAREST ' COMPENSATION INSURANCE', SIZE OF LOT `��jf, NOW ON LOT CROSS ST. (This`secflorr need not•be:completed if the permit is for one ASSESSOR i. "'•' hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE' PARCEL TEL, USE ZONE MAP OWNER ��2 C NO.Z� I certify f cit in"the performance of the-work for which.this NO. I } permit is issued,'I shall not employ any'person in any mariner' - C SPECIAL . so ds to become subject to't Wo s' mpensation Laws. ADDRESS _ r CONDITIONS y UO; ..,, Dct Applic ' NOTICE'TO APPLICANT: If, after 4kithis'Certificate of AGI ITECT OR L e NO3� JP11SEDISTRICT GROUP TYPE FIRE - BY O VITExemption, •you Should' become-subject to the Workers'' ' CONST'./ ZONE ! V au Compeomply with'such provisions or. this permit shall be provisions of the L.abor'Code, you must fofth ADDRESS ��ti `� •DV �'Z V•- -• ' with cTEL. STATISTICAL CLASSIFIC TION APT. DO,"T N deemed.revoked: „ : CONTRACTOR \ NO: LICENSED CONTRACTORS.DECLARATION- LIC. CLASS NO. DWELL.UNITS - I hereby affirm that I am licensed,urider provisions of Chapter 9 ADDRESSZ \ t NO. ?>`7 8 i (commencing with Section 7=)'of Division 3 of the Business and / LIC, SEWER MAP Professioris.Code, and my lice'nse'ii)n full force and effect, CITY G _ �/IQ�( CLASS G BK " PG = -VALIDATION F ' `� SQ.FT. NO.OF NO.OF _ CHECK •License Numbe � �'�' Lic:Class''& 41 SQ. SIZE• STORIES FAMILIES ONE s 1:v+•},,, +;r.'�: VALUATION ' j L, � �"�t,SOltL —Z� �7 DESCRIPTION OF.WORK' NEW Cont�acto�` Dafe ADD ❑ ; 92 OA_VA _ ' ❑I am exempt under Sec. ' ALTER ❑ , # 0,0 0 0' B.&P.C. for this reason'' REPAIR ❑ $ USE O .l °•° 37,5.0 ' ,_ .___-. .. _ • . '• . F ❑ _ . . D EXISTING BLDG. J^ DEMOL _._. . APPLICANT TEL. _ Si natur ' FINAL g LA O -PRINT Ccs"�•C3. t't�\ NO. I� DATE.�� ° .°...° 3 7 5 0 •I hereb emptfr . e ontrador=s License gDDRESS 2'I��� f} t\ Law for the following reason (Secfibn 7031.5, Business and FI o�2 1 s`8 5 PFdfessions Code): " PRESENT BUILDING ❑. I, as owner of the property, or my employees with. ADDRESS L _• _.,:?.�.. wages cs their sole compensation,will do the work and LOCALITY ' the structure is not intended or offered for sale(Section' • -7044, Business and Professions Code). "' MOVING ' •' TEL. - ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. W; th licensed contractors to construct the project (Sec- ADDRESS' tion 7044, Business and Professions Code). �' :2 2 0:9$• REQUIRED TOTAL SETBACK FROM _ ` '._ ? 0 0 0.o o_. .'. CONSTRUCTION LENDING AGENCY - SET BACK YARD HWY PROP.LINE WIDTH 0.0 3 0♦'� I hereby affirm that there is a construction lending agency for FRONT I :0 0 0.3 O 0 - _.the performance of the work for'which.this permit is.issued P.L. (Sec. 3097, Civ. C:). SIDE -o k 2 3 s 8 5 a .. P.L. r Q Lender's Name LDMA Ref, # Permit Fee Len der's Address - P.C.Fee$ x I certify-that I'have read.this.application..and.state that-the .Issuance Fee ♦ LDMA P/C#• above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee r Q.0) LDMA Perm.# ' ' and here y authorize representatives of this County to enter. $ upon t ab en d property for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Ilcont or ent Date @�'