HomeMy Public PortalAbout6120 TEMPLE CITY BLVD_Building__ WORKERS'COMPENSATION DECLARATION I
hereby affirm that I have certificate of consent to self APPLICATION
L I CATION BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insura ce, ! '
ere c. 3800 / COUNTY OF LOS ANGELES i BUILDING AND SAFETY
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BUILDING ,/
Certified copy is reby furnished r •FOR APP ICANT TO FILL IN -�/ ADDRESS y
❑ Certified copy i ed ill t e c ry buildi ins c- I ,ADDRESS
ere
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tion departme t
Dare i CIN ZIP �/ LOCALITY G
NO.OFBLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 'SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(•This section need not be completed If the permit is for one TRACT IBLUCK I LOT NO. MAP BOOK I PAGE I PARCEL
hundred dollars ($100)or"less.) TEL
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OWNER NO. USE.ZONE MAP
I certify that in the performance of the work for which this i NO.
permit is issued, I shall not employ any person in any manner ADDRESS/04�6 , SPECIAL CONDITIONS
CONDITIONS
so as to become subject to the Workers'Compensation Laws. + �'�— TEM
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TY
Cl ZIP
Date Applicant ARCHITECT O TEL.
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PR BY O
e: ST. ZONE U
Exemption, you should become subject to the Workers' ®4�t � �� �a�jai, W
Compensation provisions.of the Labor Code, you must forth- :ADDRESS 8 •ieFly a
with comply with such provisions or this permit shall be Nl TEL. A STATISTICAL CLASSIFICATION APT. NDO. N
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deemed revoked. � CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. �///./p CLASS NO. DWELL. UNITS
I hereby affirm that am licensed under provisions of Chapter 9 �;ADDRE NO. O�/YO SEWER MAPBill
(commencing.wi Clio 7 ) f Division 3 of the Busin LIC.
and Professions o se is in full for p } CITY CLASS ems/ VALIDATION
vII/ SQ. FT. NO. OF NO.OF CHECK BK. PG.
License Nu ber Lic. Class I u SIZE STO FAMILIES ONE
VA TI
Co.ntrae � Date 3DESCRIPTION OF WO EW ❑ $
ElI am exempt under Sec. 1 5 1A ADD ❑ ..
ALTER ❑ i
B.&P.C. for this reason REPAIR ❑ . ' $
Date: '. USE OF
EXISTING BLDG. DEMOL ❑ .
Signature APPLICA19)995
TE. FINAL v�
OWNER-BUILDER DECLARATION t. (PRIN NO/ DATE
I hereby affirm that I am exempt from the Contractor's License '
Law for the following reason (Section 7031.5, Business and .ADDRESS //• ' FINAL -•
Professions Code): PRESENT � By n:'•': st
BUILDING4'•:
❑ I, as owner of the property, or myemployees with ADDRESS 3�
wages as their sole compensation,.will do the work and .630! Lzu, ,
the structure is not intended or offered for sale(Section LOCALITY
t t!C's :R
7044, Business and Professions Code:) � MOVING TEL. .t �.�t,.a�_
❑ I,as owner of the roe CONTRACTOR NO.
property,rty,am exclusively contracting 7 I`ITAL ����;a 63
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) Mal t" "''"E
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH - f
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
I = P.L.
Lender's Ndm 77/24/921
S I ® LDMA Ref.# }:4 y 3, 2
P.C. Fee$ Permit Fee t0
Lender's dress
I cart! th I have ead t is application and state that the i Issuance F LDMA P/C#
abov inf motion is orre . 1 gr o c ly with all ounty I Investigation Fee
ordina,c and State lacing to uil g const ction, Total Fe LDMA Perm. #
and her out rize,re rese t tiv s Is ounry o enter
upon th v - entio d pr
o � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date I I