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HomeMy Public PortalAbout6450 TEMPLE CITY BLVD_Building__ l � APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES : BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUI E95 I hereby affirm that I have a certificate of consent to sen insure BUILONlG SS u/© or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) '1,— Lr �� S d LOCALITY Policy NO Company SIZE OF LO NO OF BLDOS NOW ON LOT ElCerirlg0 copy g hereby furnished SIZE CROSS ST47 ❑ Certified copy is filed wdh the couny,Golding,repecton TRACT BLOCK LOT NO department I USE ZONE MAP NO Data Applicant ASSESSOR MAP BOOK RAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS 01"'NELACW Sm YES NO COMPENSATION INSURANCE ' WITHIN Toxo FT OF scHooL7 (The section reed not be completed if the permit Is for one hundred ADDRESS DISTRICT GROUP CONST FIRE ZONE PROCESSED BY dollars($100)a Ie") /// I certify that n the performance of the work for which this permit CTTV 3 is issued I shall not erploy arry person in any manner so as to ARCHITECT OR ENOINEER TEL NO baconle b to the HlxkersTC�om�pen�9at)lon Laws STATISTICPL CLPSSffICATTON APT CONDO Date APpllcant 1mCL�+ L!/'K� G7i ADDRESS CUSS NO DWELL UNfTS NO TO APFL/CANT n after making Me Certificate Of REOUIFED TOTAL SETBACK FROM EXIST Exemption you should become subject t0 the Workers COWIRACTOR �.1 TEL NO SET BACK YARD HWA PROP UNE WITH Compensation provmons of the Labor Code you must forthwith 4CJ5 8 �r+tA FRONT comply with such provmorg or this permit shall be deemed revoked SS r ,Sr Ae � J �ZgL PLSIDE , LICENSED CONTRACTORS DECLARATION t �y� (p I Hereby affirm that I am licensed underprcv s d Chapter 9 GTA CAP/# Q-4 "_` � C� SEWER MAP (commencing with Section 7000)of Dlvg 3 of the Business and 30 FT 511E // NO OF STORES I NO OF FA ES NEW ❑ BK PG } Professions Code and IKxnse a in fun force and effect , d License Number SZ Lic Class C-34 DESGA3TIOH OFn ADD ❑ �LOATION Of O &CrapFW P '(m° $ B-�A (� _ _ e ALTER ❑ Contract �pr.,y El em exempt untlerSe�c L u� REPAIR ❑ BSPC for the reason i-AD(AN 2_ t W pl*4&C DEMOL ❑ LpM PrC W Date USE OF EXISRNG BLDG URM ❑ 1DP. Signature APPLICANT(PRWT) TEL NO LOW Perm• ACCT.: Z ❑ I as owner of the property or my employees with wages as, = 3303 108.90 their sola compensation will do the work and the structure a ADDRESS not intended or offered for sole (Section 7044 IBusinem and FINAL DATE IT Professions cpm) Nu.TIE APPIJCJJNi OR FITRIRE eUl1MNG OCLLFMNr HINOIE A HAZMpQIa WTERVL (/ff � TOT H_ 90 ❑ I as owner d the property am aXdusneN contracting With �MIOI SPECFICE D ON EAr Deus"A RRi s rsORNwm+GUM TER Tww TfE Fl�B Icensed contractors to construct the project (Section 7044 YEs❑ No❑ CHECK 108.90 Buaness and Professions Code) w1LL TW MENDED USE W TI1E alpuNa M TIE APPl1T'IM OR FROM euAp TH CrII1111S •00 OoAsT AR PEOUE A PEMM.T FCR CONa1RpCIlOr1 OR MOpF1CATICN FROM TIE$Carty CONSTRUCTION LENDING AGENCY QUIDE IM OUNITY N.vu[EMEm daTNCT ISLAONDI SEE PERKTTNG CHECKL6T FOR aacEUNE9 I hereby affirm that there Is a construction lending agency for YES No❑ rinnn� the performance of the work for which this Penns g issued(Sec WAVE ppm TERuisuEowaAnaNcumEANOTIEsaamPERKrTrNo OOM—nnWO1 9/14/95 m\ 3097 Civ C) a cKusT I urpj R 0M W REOUlEM INNER TIE LOe AN(E S GOtRlfY CODE T 1 CIVPTER 110 SECT CN9 220 1W THROIKW 120 f.0 CONCERNING N.ZARDOUa MINI 1 AN 9:03 Larder s Nang WIERIALe REPoRTN6 ANl FOR OePNlG A PERAn Fr1Gr.1 TIE 9CAOna Lenders Address o anTCR oR.¢n I certify that I hae read this applcatm and state under penaty 8 of perpuy that the above information is correct I agree to comply PC FEE PERMIT FEE O' / with all county ordinances and State laws relating to building o V COnstructi n and r aulh r representatives of this Canty ISSUANCE FEE O t r on the o arty fa Inspection s A ro i Sr INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE