The URL can be used to link to this page

Home My Public Portal About6356 TEMPLE CITY BLVD_Building__ WORKERS COMPENSATION DECLARATION ;Asj�y dafjrm•fica I have r certificate of torten, ra ce, APPLItATrOIV_ FOR BUILDING PERMIT unit or a certificate of Worker Compensation Insurance, or cenitpd,c ereof (Sec b C ) COUNTV OF LOS ANIMELES� BUILDING AND SAFETY iay o / Company BUILDING ElCertified copy Is hereby furnished FOR APPLICANT TO FILL IN ADDRESS Certified copy a bled with the county building IrTspec- BUILDING / tion department ADDRESS to Date�_•`�Applicant O y, OTY t ZIP Q LOCALITY I NO OF B NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT CROSS 57 pp COMPENSATION INSURANCE ASSESSOR �J0 3 (This section need not be completed if the permit is for one TRACE &OCK LOT NO MAP BOOK J PAGE Q/ PARCEL O.A/ hundred dollars ($100)or less TEL OWNER Q2U NO USE ZOaE MAP 1 certify that in the performance of the work for which this !O permit is issued, I shall not employ any person in any manner ADDRESS `y SPECT >_'/ CONDRIONs is so as to become subject to the Workers'Compensation LawsQ CIn ZIP / Date Applicant ARCHITECT OR TEL l NOTICE TO APPLICANT If, after making this Certificate of ENGINEER No ad DI I GROUP �T ZI C BY rQr Exemption, you should become subject to the Worker ,(_ / _ V Compensation provisions of the Labor Code, you must forth- ADDRESS •,J Q� •3 y i with comply with such provisions or this permit shall be L STATISTICAL CLASSIFICATION ` APT CONpO Z`' deemed revoked CONTRACTOR NO — 1 �trl LICENSED CONTRACTORS DECLARATIONUC CLASS NO 0/ DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chopter9 ADDRESS N t-')4Ha�SE SEWER MM _ i4 • 17 N (commencing with Section 7000)of Division 3 of the Business Cin 1 LIC t and Professions Code,and my license is in full force and effect J jR( PG 't WAUDATION lh l 1L� c (� 5O FT NO OF NO OF CHECK I�� Ucense Number "`f 1�f < Lic Clan •`r SIZE STORIES FAMILIES ONE �IlANGE •i-I /-p /� T— VALUATION Contractor ` JtjQr.) Dojo 1 l C; 1 ;\ DESCRIPTION OF WORK I / r. NEW $ �l ADD ❑ , 0001- ljifi ' il! ❑I am exempt under Sec - B 8P C for this reason REPAIR \ IIR ❑ $ /_ USE ', " r _ a n0J1 ICI.,_ . e EXISTING BLDG - DEMOL ❑ �- Signature APP(IPRINT) 7TCN TEL tp _ FINAL OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor s License Low for the following reason (Section 7031 5, Business and ADDRESS FINAL Professions Code) NT By 1 ❑ I as owner of the property, or my employees withADDRESSDIN ♦ s R wages astheir sol a compensation willdotheworkand I FT � f.a the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code ) MOVING TEL O /.� I-M-•''= ❑ 1, as owner of the property am exclusively contracting CONTRACTOR NO QQ n QJI Aj with licensed contractors to construct the project (Sec- ADDRESS (1,V�,1`7� - tion 7044, Business and Professions Code ) 11// l TI L I AL �,- CONSTRUCTION LENDING AGENCYSET a RED YARDNSVY Al PROPI. FROM EXI CHt.;; I hereby affirm that there is a construction lending agency for FRONT I the performance of the work for which this permit is issued PL '_;•lrfwji Ij (Sec 3097, Civ C ) SIDE PL Lender's Name n� LDMA Ref E Lendees Address PC Fee i Permit Fee '"" ► Ys 1 i 1i91�l7 I certify that I have read this application and state that the Invance Fee a 7.f LDMA P/C Y above information is correct I agree to comply with all County Inxeatponon Fee ordinances and State laws relating to building construction, Total F Q �� LDMA Perm 4 and here b ntatives of this County to enter ^ upo h a - inti property for inspection ur s -1 lei( SEE REVERSE FOR EXPLANATORY LANGUAGE Sigrw cant WORKERS' COMPENSATION DECLARATION reby affirm that I havea certificate of consent to ,elf APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers' Compensatiodo Insurance,nsurance, or a certified copy thereof (Sec 3800, C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Poh�77s 7F Company ElBUILDING Certified copy .s hereby furnished FOR APPLICANT TO FILL IN ADDRESS fa Certified copy Is filed with the county building Irupec- BUILDING tion d rtment SS S Dot� Applicant dTY LP - LOCALITY F BL IEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT tvle7iMI CROSS ST COMPENSATION INSURANCE (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK PAGE ':P/VPARCEL�e�( hundred dollars ($100)or leu ) TEL OWNER NO 3Si� / USE ZONE MAP I certify that in the performance of the work for which this NO permit is issued I shall not employ any person in any manner ADDRESS _/ CONDITIONS a so as to become subject to the Workers'Compensation Laws CONDRIONS O CITY G ZIP i Date Applicant ARCHITECT OR TEL O[ NOTICE TO APPLICANT If, after making this Certificate of WEER NO DISTRICT 1 P IST FIDE PROCESSED By rO Exemption, you should become subject to the Workers T/ CT Compensation provisions of the Labor Code you must forth- RESS .�fla - w o. with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO in deemed revoked CONTRACTORNO ? /J - z LICENSED CONTRACTORS DECLARATION LIC CLASS NO$,DWELL UNITS DREI hereby affirm that I am licensed under provisions of Chapter 9 ADSS NO (commenting with Section 7000)of Division 3 of the Business LIC SEWER MAP and Professions Code,and my license a in full force and effect Clay �`u BK PG VALIDATION SO NO OF NO OF CHECK - License Number Yr Uc Class SIZE STORIES FAMILIES ONE �,r/� VALUATION Contractor /!5//e/� Dote DESCRIPTION OF WORK �/�� NEW ❑ ElI am exempt under Sec iiiiiiADD ❑ flopALTER 1E:1 B 8P C for this reason REPAIR f Date USE OF - EXISTING BLDG DEMOL Signature APPLICANT TEL HNAL W -BUI DECLARATION (� NO I hereby offum that I am exempt from the Contractors License Law for the following reason (Section 7031 5, Business andADDRESS FINAL j Professions Code) NT B Elerty 1, as owner of the prop , or my employees with ADDRESS Y /"t wages as their sole compensation will do the work and loop the structure is not intended or offered for sale(Section LOCALITY 7041, Business and Professions Code ) MOVING TEL ) 1 T I_MS ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO / with licensed contractors to construct the project (Sec- ADDRESS �/ •` (0 FAL 1.2 1 - 75 tion 7044, Business and Professions Code ) CONSTRUCTION LENDING AGENCYREQUIRED BACKYARD I.M,y C FROM I �_HECK 121.7` I[E WIDTH 1 hereby affirm that there Iso construction lending agency for RONT CHANGE .90 the performance of the work for which this permit Is issued PL (Sec 3097, Civ C ) SIDE PL Lender's Name. , 111]QI I-111:111 _/ _%ji /,�/ TDMA Ref Lender s Address yrL�� P C Fee Permit Fee �� I certify that I have read this application and state that the Issuance Fee S PLDMA P/C R above information is correct I agree to comply with all County Invpngotion Fee —7 ordinances and State laws relating to building construction Total Fee Ix / LDMA Perm 0 and hereby authorize representatives of this County to enter upon the above mentioned property for inspection pun n SEE REVERLE FOR IXILANATOR'r LANGUAGE e of tit or Agent to WORKERS' COMPENSATION DECLARATION ,e 'I hereby affirm that I have a w certificate of consent self APPLICATION FOR BUILDING PERMIT insure, a certificate of Workers' Compensation Insurance or a certified co t r Sec 3800 C �yJ COUNTY OF LOS ANGELES BUILDING AND SAFETY P LC_� Policy ompaur -- / Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUDDING 3,'W ADDRESS Certified copy m filed with the county building inspec- tion department Is �� \J o---s.+[-- =Applicant � / — CITY S. C zIP / 740`0 LOCALITY �- NO OF NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LO CJ NOW ON LOT CROSS ST COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOA( PAGE, PARCEL hundred dollars ($100)or less ) L ' OWNE t40 USE ONE MAP I comfy that d the performance a the work for which this ` SPKIAL d permit is issued, 1 shall not employ any person n any manner ADDRESS CONDRfOINS O so as to become subject to the Workers'Compensation Lows ` / CITY /� ZI l o 6 U Date Applicant ARCHI O TELW te NOTICE TO APPLICANT If, after making this Certtficaof ENGINEER DISTRICT GROUP I TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers K Y CONST ZONE Compensation provisions of the Labor Code, you must forth- ADDRES� Gs•• ,,-/c�Q with comply with such provisions or this permit shall beTEL STATISTICAL CLASSIFICATION APT CONDO deemed revoked CONTRACT NO _ Z LICENSED CONTRACTORS DECLARATION uC CLASS NO DWELL UNITS_ I her affirm that I am licensed under ADDRESS NO SEWER MAP eby provisions of Chapter 9 LIC .s� (commencing with Section 70DO)of Division 3 of the Business �/ / VALIDATION and Professions Code and m lice is In full force a effect CITY CLASS BK PG v / 23 50 NO OF NO OF CHECK Af^T.a License Numbe1i��-�- Ltc Class SIZE V STORIES FAMILIES ONE N1sy e �1 VALUATION Connacta�� DESCRIPTION OF WORK NEW $2,201666,1- 3307 931. 0 ❑I am exempt under Sec Y ADD El � 1 ITEMS B&P C for this reason QAJ Z REPAIR ❑❑ $ t6j � r , Tr�OTTAnL�Lvt 931. 40 �e EXISTING BLDG DEMOL ❑ �(4ECK 931.40 Signature APPLICANT 10 � FINAL s.l'R'NX •� OWNER-BUILDER DECLARATION (PRINT f I hereby affirm that I am exempt from the Contractor sLicense DATE/(�/ , Low for the following reason (Section 7031 5 Business and ADDRESS • - r d'`' FINAL nn�L_rR�� Professions Code) EM BT rn0000-0001 9//19//t89 es BUILDING J/!6 I, as owner of the property, or my employewith BODREu 1 AN10:0n theses as then sole compensation,w willdo the work and LOCALITY the structure is not intended offered for sole(Section 7044, Business and Professions Code ) MOVING TEL ❑ I os owner of the property, am exclusively contracting CONTRACTOR NO / with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Profeaslons Code ) CONSTRUCTION LENDING AGENCY I D YARD F/N'1' TOTAL SETBACK FROMEXIST 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 PL Lender s Name //�L LDMA Ref N PC Fee f Lender's Address .14 Permit Fee , 0 1 certify th have read this application and state that the Issuance Fee LDMA P/C N above mfg0lotion is in I agree to comply with all County Investigation Fee ordinan nd a luting to building construction Total Fee LDMA Perm N ` and he a ooze epr ntahves of this County to enter ^ upo abo a-me ion property for inspection p � SFE REVERIE FOR EXPLANATORY LANGUAGE Signa Nr o f mn lior Agent Date