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Home My Public Portal About6023 TEMPLE CITY BLVD_Building__ I WORKERS'COMPENSATION DECLARATION .t •• of coent to sel insure, oraa certif catte of Wo ke s'tificate Compensat on Insurance, APPLICATION F R BUILDING PERM1T or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Companymom=-- BUILDING Vertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ertified copy is filed with the county building i '4p BUILDING r t5ion department ADDRESS '�v �! LOCALITY /� NEAREST Date Applicant CITY (j ZIP CROSS ST. CERTIF ICAT OF EXEMP O FROM WORKERS' SIZE OF LOT (rD I O.OF BLDGS. ASSESSOR COMPENSAT INSURANCE NOW ON LOT' MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. WO TEL. Q R—q SPECIAL ?- I certify that in the performance of the work for w ich •is OWNER y��L t�� NO.Z97-3 7 CONDITIONS 0- ermit is issued,I shall not em to an person in an ner /r DISTRI GROUP TYPE FIRE PRO SSED BY so as to become subject to the Work y p ns is aws. ADDRESS Zell/��/�y SIM" CONST. { ZONE Date Applic CITY `� STATISTICAL CLASSIFICATION tl/ APT. CONDO �- NOTICE TO APPLICANT: If, Kmaking this Certificate of ARCHITECT OR TEL. U f� ENGINEER NO. CLASS NO. _DWELL. UNITS Exemption, you should eCome subject to the Workers' fL Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be TEL �Q '. deemed revoked. CONTRACTOR * f/ NO (J BK. PG, ky VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS?Q, NO. VALUATION (commencing with Section 7000)of Division 3 of the Business andLIC. _f Professions Code, and my license is in full force and effect. CITY CLASS $ , SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE $ Contractor Date DESCRIPTION OF WORK NEW ❑ ADD ❑ V 9 E] I am exempt under Sec. ALTER FINAL # 00000 DATEl B.BP.C. for this reason REPAIR USE OF FINAL Date: DEMOL ❑ I a - 87,38 EXISTING BLDG. EL. p`Q Signature APPLICA NT �D. �W-NO. By / o 1. 19 0.2 2 5 (PROWNER-BUILDER DECLARATION I 1.01 -84 I hereby affirm that I am exempt from the Contractor's License ADDRESS r i �� 7 T� , Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT 1:1 BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a.construction lending agency for FRONT the performance of the work for which this permit is issued P.L. tSec. 3097,Civ. C.). SIDE o P.L. Lender's Name L 18 P.C.Fee$ LPermitee 61 Lender's Address /��I certify that I have read this application and state that the Fee V s�above information is correct. I a ee to comply with all County ordinances and State law r ing to building construction, e D and her uthorize re re tatives of this County to enter un e m ti a roperty for inspection purposes. o �f SEE REVERSE FOR EXPLANATORY LANGUAGE n Signature of Applicant or Agent Date ®s T• WORKERS'COMPENSATION DECLARATION � • ,1 hereby,affirm that I have a certificate of consent to self APPLICATION F®R BUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company .� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS {'! �! iyt �� a` � � TI ❑ Certified copy is filed with the county building inspec- BUILDING n r J tion department. ADDRESS l✓ •� _� +:' ;,t', i A!- !1 LOCALITY 1��✓i'�"C�' ( ! . NEAREST Date Applicant CITY '�; y✓ / ( L e-A ZIP 7.f �� CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' / NO.OF BLDGS. ASSESSOR ! L COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP TRACT BLOCK LOT NO. �� NO O () hundred dollars($100)or less.) >_ c +TEL. t �� ,-v SPECIAL t�s`�/'lt Q' OWNER .�y!/��) : �L`NO.—� ';I CONDITIONS �' O 1 certify that in the performance of the work for which this i DISTRICT GROUP TYPE FIRE PRO SSE 8Y u permit is issued, I shall not employAny person in any manner ` L'� so as to become subject to the W Y ers' n pensation L s. ADDRESS �i �� n CON'S_ ZONE �. 1I r + +rn ITY �Lr "�' �� ' A. ZIP' / f L� r K V 3 Date 1' Applicant 'V ` STATISTICAL CLASSIFICATION A . CONDO. W ARCHITECT OR NOTICE TO APPLICANT: If, after making this Certifi ate Of TEL. ! Exemption, you should become subject to the Workers .' ENGINEER NO. CLASS NO. �( DWELL. UNITS to Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be deemed revoked. TEL' BK.�PG, f/dd VALIDATION -CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CIT CLASS $ r SQ. Fi�, NO.OF NO.OF CHECK License Number Lic.Class SIZE �3"�a STORIES FAMILIES ONE /�� D Q Q Contractor Date DESCRIPTION OF WORK . NEW ❑ ❑ ADD I am exempt from the licensing requirements as I am a �— fi �� e licensed architect or a registered professional engineer ALTER ❑ FINAL �. acting in my professional capacity (Section 7051, L .,7p _ �J te. �', " REPAIR ❑ DATE Business and Professions Code). '�1 '.��or,(G Js4 DEMOL ❑ By AL ,�' ; Lic.or Reg.No. _Date 7 APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): Y PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL ` ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. v\ with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD, HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for [Investigation RONT the performance of the work for which this permit is issued L f D (Sec. 3097, Civ. C.). DE L Lender's Name / Lender's Address Fee$ Permit Fee ' I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Fee 3 ordinances and State laws relating to building construction, and hereby uthoriza representativvesrbf this County to enter Total Fee u n the ve-mentioned partyr inspection purposes. a ' G • I JQ �t�� L/ SEE REVERSE FOR EXPLANATORY LANGUAGE ° 6 Signature of Applica or Agent Dote ®s