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 @�'