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Home My Public Portal About6029-6031 TEMPLE CITY BLVD_Building__ WORKERS'COMPENSATION DECLARATION i; I hereby affirm that I•have a certificate of consent to self I fl D 1 insure, or a certificate of Workers'Compensation Insurance, ( APPLICATION F R• SUI I PERMIT or a certified copy thereaf(S 00, Lab. .) �. 7J � COUNTY OF LOS ANGELES BUILDING"AND SAFETY. , Policy No. Company :.... •.... , r] , Certified copy is hereby furnished. FOR APPLICANT TO FILL IN. _. ADDRESS C7/ Certified copy is filed with the county building inspec- [ADDR ING �ly�^ tion department. ESS y / NEAREST Date Applicant % ,f( r. ZIP ( 7 CROSS ST. CERTIFICATE.OF EXEMPTION FROM WORKERS'. / -NO.OF BLDGS. -ASSESSOR COMPENSATION INSURANCE• OF LOT /� NOW ON LOT MAP BOOK PAG PARCEL (This section need not be completed if the permit is for one USE ZONE" ESPECIAL O® hundred,dollars($100)or less.) T BLOCK LOT NO. TEL 7Icertify that in.tha performance of the•work'for which this ER iJ/eNO 7 I DITIONS ®- DIST GROUP TYPE FIRE PROCESSED BY �: permit is issued,I shall not employ any person in any manner ESS �. CONST. ZONE tJ so as to become subject to the Workers'Compensation Laws. - ` tv' d Date Applicant ZIP STATISTICAL C I TION APTCONDO. qNOTICE"TO APPLICANT: 'If, after making this Certificate 'of ITECT OR ✓,: NEER' NO. CLASS NO. DWELL. UNITS Exemption, you should become. subject to- the Workers' , Compensation provisions of the,Labor Code,*you must forth- ADDRESS SEWER MAP with comply with such provisions or This permit shall.be TEL, z. VALIDATION deemed revoked. B CONTRACTOR (y LICENSED CONTRACTORS DECLARATION ®� I hereby affirm that I ani licensed under ptovisionss-of Chapter 9 ADDRESS /// VALUATIO (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code, and my license,is in_full force a ffect. CITY C _ SQ.FT: NO.OF NO.,OF HECK License Number. r ;Lic.Class SIZE STORIES FAMILIES ONE NEW $., Contractor .pate DESCRIPTION OF WORK ; ! ADD ❑ - . .❑I am exempt under Sec: t ALTER ❑ FINAL B.BP.C.,for this reason • ' REPAIR ❑ DATE J Q Date: USE OF FINAL EXISTING BLDG. DEMOL By Signature APPLICANT. TEL. OWNER-BUILDER DECLARATION PRINT NO. .:. � I hereby affirm that I am exempt from the Contractor's License fj Law for the following reason (Section 7031.5, Business and :',`ADDRESS = a Professions Code): Or PRESENT :BUILDING I"I, as owner of the property, or my.employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY _ 7044,.Business and Professions Code). MOVING TEL. ❑ I,as owner of the property.;am exclusively contracting . CONTRACTOR NO. with licensed contractors td.construct the-project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. O CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH t ' 0 4 " A I hereby affirm that there-is a construction lending agency for FRONT 0 70 0 0 0 the.performance of the work for which this permit i5•Issued' P.L: iSec. 3097, Civ. C.'): SIDE 20, b a 5 0 P.L. Lender's Name `' ° ° 6_'S0i - Lender's Address f R,.C. Fee$ Permit Fae 04, 1 35�8•4•' I certify that I'haVe-read•fhis application and state'that;the Issuance.Fee 4s above information is correct. I agree.to comply with.all County Investigation'Fee ordinances and State laws relating to uilding construction, Total Feb A and hereb uthoriie representatives this County to,enter upon th ve- ti d proper r in pectia.%41erposes. - I uSEE REVERSE FOR EXPLANATORY LANGUAGE 5 a re App canto ent Date ®s WORKERS'COMPENSATION CIECLARATION hereby affirm that I have�INcertificate of.consent self APPLICATION F OR BUILDING PERMIT insure, or a certificate of orkers'Compensation Insurance, or a certifiedAka-2.3 eco 2� es, 3800,.Lab Pal Icy No. (� o an. `t'� GG COUNTY OF LOS ANGELES BUILDING AND SAFETY BUILDING J _s ,Q Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS-11;" -031 Aot Certified copy is filed with the county build'naQ inspec- BUILDING D tion department. ADDRESS ' e l Jj LOCALITY p NEAREST Date Applicant CITY �/r ZIP pQ CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' �j NO..OF BLDGS. / -ASSESSOR COMPENSATION INSURANCE SIZE OF LOT b U NOW ON LOT I MAP BOOK PAGE PARCEL (This section need not be completed if the permit it.for one USE ZONE MAP TRACT BLOCK LOT NO. NO. hundred dollars($100)or less.) - - TEL. �s SPECIAL ! 'I certify that in the performance of the work for which this OWNER NO. ��i 1111 CONDITIONS permit is issued, I shall not•em to an arson in an manner DISTRICT .GROUP TYPE FIRE PR ED BY O so as to become subject to the Workers'Compensation Laws. ADDRESS !pC CONST. ZONE �+ 09 CITY' ZIP J Q Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. UF- NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ENGINEER - NO. ' CLASS NO. DWELL.UNITS vo 'Exemption, you should become subject to the Workers' 0. Compensation provisions of the Labor Code, you must forth- ADDRESS A SEWER MAP v) with comply with such provisions or this permit.shall be 1�_� z deemed revoked. J ev ^e , NOEL... $ BK. L PG, VALIDATION CONTRACTOR ,.LICENSED CONTRACTORS DECLARATION LIC.I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (� E CLK Ie_e�NO. c VALUAT ON(commencing with Section 7000)of Division 3 of the Business and LIC• QProfessions Code, and m license is in'full force and effect. CITY _ I t CLASS iV $ ►!�, SQ.FT NO.OF 7�7 NO.OF CHECKLicense Number ` �`Lic.Class ' SIZE STORIESL FAMILIES '7 ONE�-e �i 4L NEw $ D n P 5 ! AContractor Date DESC4SIPTION OF ORK ADD - te•ot`I am exempt underSec. "� Z �� p),IJ Oii. ALTER FINAL / 6?_ 1.57.'• . - •• DATE�lB.&P.C. for this reason_ REPAIR USE OF L FINA o 2 1, ! t�. Date: v 2 WLO $ DEMOL ❑EXISTING BLDG.Signature APPLICANT p p8y6 b s PDQ T ' W OWNER-BUILDER DECLARATION PRINT �- ebr". G' C OzBG`ZS d$ 6 {� o'o i U I hereby affirm that I am exempt from the Contractor's License _lt�wL � ,V� TC ADDRESS Law for the following-reason.(Section 7031.5, Business and ! � _ Professions Code): PR ENT E -I, as owner of the property, or my employees with 'BU 2 0 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 CONTVRRAACTOR NO. with licensed contractors to construct the project'(Sec- ADDRESS r 016!i 9 A 'tion 7044, Business and Professions Code). t'. 0- CONSTRUCTION ' REQUIRED TOTAL SETBACK FROM EXIST. C ° G C CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE• WIDTH n r 7 1 hereby'affirm that there is a construction lending agency for FRONT Cr �' " the performance.of the work for which this permit is issued` P.L. ® �'4 2 0 - tSec. 3097, Civ. C.). SIDE o P.L. `v Lender's Name a P.C. Fee$ Permit Fee Lender's Address I / r I'certify that I have read this ap lication and state'that the !(� Issuance Fee 6 ��• above information is correct..I ag" a to mply with,all County Investigation Fee �j ordinances and'State laws rela ng t uilding construction, Total.Fee nL and here authorize repress ativ of this County to enter upon e a ov a io d ope for inspection purposes. o -�� ✓ ; SEE REVERSE FOR EXPLANATORY LANGUAGE ignature bf Applicant or Agent Date- ®s WORKERS,COMPENSATION DECLARATION hereby affirm that I have certificate of consent td Self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, La .) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS a? l Certified copy is filed with the county building inspec- [ADDRES UILDING �7 C -f tion department. DDRESS 60� C- 9 v' l LOCALITY L NEAREST Date Applicant TY t<r C'i ZIP CRO55 ST. CERTIFICATE OF EXEMPTIOr4 FROM WORKERS' ) NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE ZE OF LOT { 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.) ACT BLOCK LOT NO. ,/ NO. TEL. L-IJ SPECIAL I certify that in the performance of the work for which this WNER NO. CONDITIONS CL permit is issued, I shall not employ any person in any manner DISTRICT GROUP JTYPE FIRE PR ESSED BY O F--> CONST. ZONE 61 so as to become subject to the Workers'Compensation Laws. �S.��T->C . / s U / Jt !C ~� 3 alt Date Applicant CITY ZIP 0STATISTICAL CLASSIFICATION APT. CONDO. V NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ENGINEER - X NO. CLASS NO. a /f DWELL. UNITS W Exemption, you should become subject to the Workers' Q Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N with comply with such provisions or this permit shall be le 2v TEL.Z BK L �j VALIDATION deemed revoked. CONTRACTOR Ji 1 NO. O zG' LICENSED CONTRACTORS DECLARATION LIC. �1 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS L(: �;� k e— Cl/ NO. 7 Z VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is i full force and effect. CITY G t'- CLASS $ R-1 SQ. FT. g NO.OF NO. OF 7 CHECK License Nu V.ic.Class_ SIZE ��`� STORIES FAMILIES �_ ONE , Contract o Dare DESCRIPTION OF WORK K NEW I a xempt under Sec. ' le,w ADD ❑ ALTER ❑ FINAL B.BP.C. for this reason USE OF REPAIR ❑ DATE CG Date: DEMOL FINAL EXISTING BLDG. ❑ By Signature APPLICANT ) D 1 ./�f r TEL. !� OWNER-BUILDER DECLARATION PRINT �JQ bS( Q t � NO.� I hereby affirm that I am exempt from the Contractor's License / -�� j , Law for the following reason (Section 7031.5, Business and ADDRESS ZZ- - f / M rC Professions Code): 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. 1, 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. (Sec. 3097, Civ. C.). SIDE 0 P.L. Lender's Name a P.C. Feet Permit Fee Lender's Address 2 p I certify that I have read this applica"on and state that the ✓ �� Issuance Fee S above information is correct. Ia ee o amply with aN County Investigation Fee ordinances and State lows r in building co struction, Total Fee and here uth ize repres to s of this Co ty to enter ` upon ea o - e '6 apro rty for insp ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of AlWicant or Agent Date ®s