HomeMy Public PortalAbout5951 TEMPLE CITY BLVD_Building__ WOILKERS' CO&PENSATION DECLARATION
here o affirm that I have r ce' C mte•of consent to pelf APPLICATION FOR'- B U I L'D I N G P E RM I T
I ,insure, or a certificate of Workers' Compensation Insurance, -
or a'cerfied copy thereof(Sec. 3800, Lab. C.) ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polley NO.42-4 Q• G Q
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING'''
ADDRESS � S •Orn,
, tion department. �.
Date• vAppltcant CITY' ZIP LOCALNO.OF ITY
CER IFICATE OF EXEMPTI FROM WORKERS' SIZE'OF LOT NOW ON LO NEAREST
CROSS ST. '• '
COMPENSATION SURANCE _may . ASSESSOR (�
(This'section need not be completed if the permit is for:one TRACT BLOCK /°� LOT NO. ` ✓ MAP BOOK �d PAGE PARCEL��
! hundred dollars($100)or less.) TEL,
OWNER � (� NO,'(p� USE ZONE MAP
,I certify that in the performance of the.+work forSPECIAL
which this NO.
permit is issued, I shall not
O employ any person in any manner ADDRESS S �' Gf ��r/ ' ' CONDITIONS CL '
so as to become subject to the Workers'Compensation Laws. O
c CITY . ZIP U
Date Applicant ARCHITECT OR f<eZee.A&e04E.5 TEL.
�'- DISTRICT ];GROUP. TYPE FIRE PROCESSED BY O
!. NOTICE TO APPLICANT: If,• after making this Certificate of ENGINEER NO: CONST. ZONE. F
Exemption; you should .become subject to the Workers' y # 7 , / w
Compensation provisions of the Labor Code, you must forth ADDRESS / �7.�t$ ?u/ / C.y �U p V. 3 p-
with comply with such.provisions,or this permit shall be TEL. N
�¢�rn ree5• STATISTICAL CLASSIFICATION APT. CONDO: Z'
.
deemed revoked. CONTRi4CTOR NO. _ 0D _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.�DWELL. UNITS
I hereby affirm that I am'licensed under provisions of Chapter 9 ADDRESS 0 NO. (� Now
LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business _ RR '
and Professions Code„and my license is in full force and effect. CITY f• CLASS 1-� BK A.:+VALIDATION
SQ: FT., NO. OF NO.OF CHECK
License Number Lic.,Class SIZE ZQD STORIES FAMILIESONE (:;_7 s
rC-Qil e� VALUATION '
+. Contractor�� Coy�Sik rr�`oa 3 DESCRIPTION'OF WORK NEW E] $
� ,....
i El am exempt under Sec. • f � PL r AD ER ElI - ► _ � ��j��l.`'
B.BP.C. for this reason REPAIR El $ I°.TA: 3b_ 'a
U$E,OF' _ £
EXISTING BLDG. DEMOL ❑ ±1_
APPLICANT TEL.. t' ” F 1,•j
Signature FINAL CHANGE
(PRINT) NO. n_.
DECLARATIOON DATE -7 7-o/Z
I hereby affir:1E.01-BUILDER
am exempt from the Contractor's License
Law for the fg reason (Section 7031.5, Business and ADDRESS FINAL
5 Professions Code /� i i. +`.
J PRESENT BY �. ""}:�' arflf t
BUILDING• W?: , a
❑ I, as owner of the property,,or m employees with L �' O� 7
p P Y% YADDRESS .. rn'f
wages as their sole compensation,will do they and ??f'i + �'
LOCALITY °-'
the'structure is not intended or'offered for.sale(Section ' -
7044, Business and Professions Code.) MOVING TEL. , 1 T E'MS
❑ I•,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS ! , ; O I. L
tion 7044, Business and Professions Code.) ' _1 :, + r r,'•1�. _: ;.6 "s'
REQUIRED TOTAL-SETBACK FROM EXIST.
r CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
l the perforntance.:of the work for wFiich this permit is'issued. P.L. i
(Sec, 3097, Civ. C.). SIDE +
P.L.
Lender's.Name
3 ! S�j� /� LDMA Ref.#
P.
Fee$ 1:1 Permit Fee y
!, Lender's Address-
I certify that I have Fead this application and state that the I 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, i Total Fee / •Q LDMA Perm. #
and hereby authorize representatives of this County to enter
f upon th above- ent oMR
erlty for inspection purposes.
�- SEE REVERSE FOR EXPLANATORY LANGUAGE j
j Signa ure.of Applicant or Agent Date j