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HomeMy Public PortalAbout6360 TEMPLE CITY BLVD_Building__ WORKERS COMPENSATION DECLARATION sure o affirm that I have r certificate of consent r ,elf APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers Compensation Insurance, or a certified copy thereof (Sec 3800,pLob C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No 22077 Company— $4f4_V C.f' ElCertified copy is hereby furnished FOR APPLICANT TO FILL IN n ADDRESS 3li O ❑ Certified mpy Is filed with the county building Inspec- �M 6 b Q M C 0 C +tY 910 nion�yde-paartment Date '3-31-9 2 Applicant QW eN' aTr 'e r �C e C I f"Y ZIP 91 7 80 LOCAUTv NO O BOUT RO ST CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT $-(POO NOW ON LOT 47 COMPENSATION INSURANCE his section need not be completed if the permit is for one TRACT 00040 1 BLOCK LOT NO 00 7 MAP R is 3 PAGE 1PARCEL o0 f+undred dollars ($100) or less ) TEL OWNER OWN OS No 359-3211 USE ZONE MAP I certify that in the performance of the work for which this NO .I permit Is issued, I shall not employ any person In any manner ADDRESS N 2 EaS �r (. W r N l`f✓R /�/ CONp TIONS O so as to become subject to the Workers'Compensation Laws V cm e L µno 14 e zip 91131 Date Applicant ARCHITECT OR TEl NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO _ DISTRICT GRWP ODNST I E PROCESSED By O Exemption, you should become subject to the Workers' D O 1 Compensation provisions of the Labor Code, you must forth- RESS 0 J with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION AP7 J CONDO deemed revoked CTOR OWCAf NO 3sq ' 3211 z LICENSED CONTRACTORS DECLARATIONuC CLASS NO DWELL UNI75/ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O 1 !'L"s/f Q NO 14 H 7 S SEMR MAP (commencing with Section 7OD0)of Division 3 of the Business - LIC and Profession Code,and my license is in full force and effect CITY CN f0 NJ+.i C CLASS BK VALIDATION NO INO OF CHECK License Number Lf q 4 7�$ Lac Class sl' 0� ORIE 1 FAMILIES ( ONE � ��n� � VALUATION Contractor /n/Ln'T '/ Date 3-3-9 Z DESCRIPTION OF WORK to NEW ❑ _ ElI am exempt under Sec <jtvf C ,} a ADD LJpool ALTER ❑ B BP C for this reason REPAIR S Date 115E O EXISTING BLDG F DEMOL T TEL Signature OWNER-BUILDER DECLARATION TION'r-/ APPLICANT) owe/V CION - . NO —3zif FINAL / n DATE I hereby affirm that I g r exempt from the 31 5 Business license Low for the following reason (Semon 7031 5 Business and 0 /'t14 e FINAL i Professions Code) NT !Y - r a ❑ I, as owner of the o or m employees with BUILDING' H- -T`T property, YtADDRESS my 7c wages as their sole compensation, red f o the work and LOCALITY the structure is not amended or offered for ale(Section 1�EI 7044 Business and Professions Code ) MOVING TEL ' + ❑ I as owner of the property,am exclusively contracting CONTRACTOR NO c with licensed contractors to construct the project (Sec- 113-1 AL i`2 �" - - tion 70", Business and Professions Code ADDRESS / � O r _HEC F: L^,..7` CONSTRUCTION LENDING AGENCYSET BACKD yAgD HLyy O P do FROM VADTH EXIST I hereby affirm that there B a construction lending agency for FRONT the performance of the work for which this permit Is issued P L (Sec 3097 Civ C ) SIDE S Lender's Name Pl. L [ItAllI-E I[If.l ?/ +3/Tom,-' ^ P C Fee Perna Fee 'v v LDMA Rf N il�_]o Lender's Address Z� a I certify that I have read this application and state that the Issuance Fee /- LDMA P/C N Pilo a above information is correct I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction Total Fee LDMA Perm N and hereby authorize representatives of this County to enter - upon thea ve-mentioned property fair inspection purposes , &O-4--t 3 -3-9Z LEE REVEM FOR EXPLANATORY LANWAOE Signature of Applicant or Agent Dote WORKERS' COMPENSATION DECLARATION r APPLICATION FOR BUILDING PERMIT I•herdby affirm thot I have a certificate of consent to self insure er a certificate of Workers Compensation Insurance, - /'�orr b cc7e'riiified_cc thereof,(Sec 3800, C) COUNTY OF LOS ANGELES BUILDING AND SAFETY icy tfo��``��!! Compon - BUILDING ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building Inspec- BUILDING hon d Date Applicant /�opa ent ADDRESS 2 Z / Jy.Jjz/ OTv7 ZIP 1 WCAM CERTIFICATE OF EXEMPTION FROM WORKERSSIZE OF LOT NOV/ON LOT NEAREST ST COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK BOT NO MAP BOOK PAGE PARCEL r� hundred dollars ($100)or less ) TEL ' OWNER rT I NO _ ( USE ZONE 1 certify that in the performance of the work for which this — / SPECIAL 2 permit is Issued shall not employ any person in any manner ADDRESS t2 CONDITIONS O so as to become subject to the Workers Compensation LawsU CITYfU! zip Cl 16 L Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BV NOTICE TO APPLICANT If, after making this Certificate of ENC>INEER NO 1 CONST ' ZOFIE- Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forth- ADDRESS �P ✓ 'U _ '. with comply with such provisions or this permit sholl beTEL 1 STATISTICAL CLASSIFICATION A T GO DO Z deemed revoked l(� CONTRACTOR NO 1 / 1 CI IC LICENSED CONTRACTORS DECLARATION LIC CLASS No DWELL UNITS_., tha I hereby affirm t I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP (commencing with Section 70DO)of Division 3 of the Business LIC V and Professions Code,and my license a in full force and effect Cin CLASS BK PG VALIDATION 2 SO FT NO OF NO OF CHECK 1_ License Number�-'1,44-)'Sn Lic Class SIZE STORIES FAAVUES ONE VALUATION CH�'V (- Contractor Owan Data LI I1 I ct t DESCRIPTION OF WORK NEW .fSl El am exempt under Sec -' ` ADD ❑ : ► 1�I] Q—I�u01 iiii., ALTER t. ID (!5�' 1 Af 110 CI B&P C for this reason Coe REPAIR ❑ S \ _ Date - EXISTING BLDG DF/AOL ❑ -`• v` ,, v �1\�\i� \. . s - Signature APPLICANT TEOL FINAL OWNER-BUILDER DECLARATION Q (PRINT) ND DATE L I hereby off irm that I am exempt from The Contractor's License ^� _ O� � Law for the following reason (Section 7031 5, Business and ADDRESS QJ 1 FINAL ✓ ,-Lit Professions Code) - By __ 1, as owner of the property, or my employees with BUILDING '_ I—'�- wages as their sole compensation will do the work and n/ - j j I -7 j the structure is not intended or offered for sale(Section LOCALITY , �, f - - 1• � i�7.DL 7044, Business and Professions Code ) MOVING TEL () .C�-ICT-( 7 i ❑ 1, as owner of the roe y ng .n `� 1,—t. property, am exclusive) contracts CONTRACTOR � u I with licensed contractors to construct the project (Sec ADDRESS /� ,�r(� C HANG .Cl ' ' hon 7044, Business and Professions Code ) CONSTRUCTION LENDING AGENCY \ I YARD flW1' TOTALPROP SETBACK FROM I 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 ) SIDEi�` I PL Lender s Name ORef N ' PC Fee f O Permn Fee Z Lender s Address o I certify that I have read this application and state that the J Isuwnce Fee 7 LDMA P/C N - above information is correct I agree to comply with all County Investigaiian Fee .s ordinances and State jaws relating to building construction, Towl Fee r� . (DMA Perm p and hereby authorize re sentatives of this County to enter upon th pd pro erty far inspection p rpo q L _ SU IIEVD6E roe EXKANATORY LANGUR" ^ oo amt e -