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HomeMy WebLinkAbout8458AWORKERS COMPENSATION DECLARATION4Kk: i J hereby affirm ,that i have, a certificate . of consent self ►P P L I CAVI 0 N F O D] I l DIN PERMIT r rc, insure, or a certificate aIf'Workers' Compensation Insurance, R. ;tea 6; 0605-86 or a certified copy (hereof (Sec: 3800, Lab. - T 7�WC005�279�g_Q04 Wf oTl Vide 35/B COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy, o, ompany Certified:copy.'is hereby furnished., FOR APPLICANT TO FILL IN j BUILDING j ADDRESS 24377 E. Sylvan Glen Road Certifted'copy Is filed'with the county buildin=g inspec-_— t3UILDING 24377.E.. Sylvan. Glen Road tion departntent. ADDRESS 5 19., $e , •.. THE.,OEN , Date — Applicant ,PG CITY Dj ariond Bar ZIP 9-17.65 LOCALITY Dia:T1Qnd Bar YI 'CERTIFICATE OF EXEMPTION FROM WORKERS' "' - -. NO. OF BLDGS. NEAREST-.... ` COMPENSATION INSURANCE' ­ SIZE OF LOT NOW ON LOT CROSS. ST._., r (This section need not be completed if the' permit is-for -- :35754 86 =1Sone O(Z'. hundred dollars ($100) or,less.) TRACT BLOCK LOT NO. PAGE: PARCEL I certii'y`that in .the perf=ormance of the'work for whickt` this TEL. aWNER NO: ,: ` USENEP / _ . . to.•GJ permit is issued, l shall not employ any person in any manner ADDRESS•C•X 3329 SPECIAL - IL a so as to become''sublect to the Workers' Compensation Laws. CONDITIONS V CITY Covina ZIP _ 91722 ;Le A III cant f this Certificate of aOTICE TO APPLICANT:, Iaftei� making ARCHITECT OR TEL 'ENGINEER NO. DISTgICT GROUP -TYPE FIRE PROCESSED BY Exemption, you should become subject' to ` the Workers' i �p CONST. 1. 7 Compensation provisions of the Labor Code, you must forth- ADDRESS 314 N. F1xS.t Arcadia --- T!// y with .comply .with such =provisions or this, permit shall be deemed, revoker) _ __ _ TEL, STATISTICAL CLASSSIIFIICATION APT.Je0NDO.,! DECLARATION, '•+ CONTRACTOR UP NO. I .�--� CLASS NO. DWELL. UNITS LICENSED CONTRACTORS . •, . I hereby affirm that I am licensed. under, provisions of Chapter 9 — --- ---- TIC; As; above. 37.1580 ADDRESS NO. (commenting with Section, 7000) of D•Ivision 3'of.the Business and _ __- _ _._ -. __ LIC. I SEWER MAP SE Professions Code; and my license is in full force and effect. CITY CLASS B' VAUgf 01647 A 371580 , & License Number Lic. Class SQ. •FT. _, . SIZE NO. OF STORIES NO OF FAMILIES CHECK ONE BK. PG. ¢ �,;� r 2 1 THE. ANDEN GROUP 5-197-86 Dat DESCRIPTION OF WORK ._ NEW VALUATION 56,343 l f �i 9i 1'9 Contractor e ..,., ADD $ am exempt under Sec. _ _. ___Cara e._ 4 ,'. ® ® G { ALTER Q B.&P.C, for this reason _ REPAIR 0 $ o6 5-86. Date: USE OF EXISTING BLDG, DEMOL 0 Signature OWNER -BUILDER DECLARATION APPLICANT TEL. . PRINT THE. GRpUP NO. r' - FINAL p DATE•---�Z�'gli-- I -hereby affirm that l am exempt from •the Contractor's License : ajj( ive AS 'aw for the following reason (Section 7031.5, Business and iifessions Code): I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting -.-.. with licensed -contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for ,the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Cnnf-i nP. i -al T11 i nnis Lender's Address 231 'S. LaSalle.,Chic" IL I .certify that I have read this application and state that 168693 above information is correct. I agree to comply with all County ordinances an tate laws relating to building construction, - and hereby u orize representatives of this County to enter upon The e- ntioned property for inspection purposes. Signature of Applicant or AgentD/ ate TEL.. R NO. .. M --YARD HWY ,., CFTiaerV � oono r rn¢ \AAnru 1 Q - - Permit Fee 'I 'IQ nn Issuance Fee 1;a-. 50 Investigation Fee _ _..Total Fee 349.50 FINAL Y �+�r , Y _ LDMA Ref. It LDMA-109- SEE REVERS FOR EXPLANATORY LANGUAGE i J ,} LDMA Ref. It LDMA-109- SEE REVERS FOR EXPLANATORY LANGUAGE i©1 i .4 r U ;tea 6; 0605-86 s - T • t, 4, ir i©1 PLANS TO APPLICANT To:. Returned 40.1 Date No. I Date Approved 'Required Approvals < Date Received Yes No or Approved Water Certificate INSPECTOR'S NOTES 77- 7 7777777777777— a OWER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law, for the following reason. (Sec. 7031:5) Business and professions Code: Any,city or county which requires a permit to construct, alter,, improve; demolish; or repair any structure; prior to its issuance, also requires the applicant for such permit to file a signed statement thathe is licensed pursuant to,the provisions of the Con-, tractor's License Law (Chapter 9) (commencing with S.ec-' tion 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any, violation. of Section 7031.5 by any applicant for a permit subjopft, the applicant to a civil penalty of not:more, than: five. hundred dollars ($500):J:. ❑ I, as owner of the property, or my employees with wages as their sole compensation,, will do the work, and the structure is'Rof intended'or offered for sale (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himse f through ,his own employeest i provided that such it.. pr,ovements, are not intenq'ed or;, offered for sale. If, X however, the: building or improvement is sold within one year of 'completion, the'owner=builder will have the burden of proving that he did not build or improve for the purpose of sale)." ❑ '`I 'ds'owner of the property, am exclusively contras ting with licensed contractors to construct the project (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or'improves thereon;"and who contracts for such prorecis'with a contract or(sf: licensed pursuant to the Contractor's License Law). ❑ I am exempt under Sec. B.&P.C. for this reason Date Owner 1 INSPECTOR'S;: NOTES. .. 777T, w Health Department Fire. Department Grading Geological Pedestrian Protection, (Fence) (Canopy) Special Inspection (Cont.) (Masonry) (Welding) Lot Drainage - Parking + Approvals Date _.Inspectors Signature Location— . „"' _ - (Setback & Yards)tz . _ .. Foundations " Slab" Frame Energy Insulation - R, Lath/Drywall— Interior d n Lath—Exterior s : •� ; House Number— a . Correct & Posted f�. Final— a Enter on Front OWER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law, for the following reason. (Sec. 7031:5) Business and professions Code: Any,city or county which requires a permit to construct, alter,, improve; demolish; or repair any structure; prior to its issuance, also requires the applicant for such permit to file a signed statement thathe is licensed pursuant to,the provisions of the Con-, tractor's License Law (Chapter 9) (commencing with S.ec-' tion 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any, violation. of Section 7031.5 by any applicant for a permit subjopft, the applicant to a civil penalty of not:more, than: five. hundred dollars ($500):J:. ❑ I, as owner of the property, or my employees with wages as their sole compensation,, will do the work, and the structure is'Rof intended'or offered for sale (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himse f through ,his own employeest i provided that such it.. pr,ovements, are not intenq'ed or;, offered for sale. If, X however, the: building or improvement is sold within one year of 'completion, the'owner=builder will have the burden of proving that he did not build or improve for the purpose of sale)." ❑ '`I 'ds'owner of the property, am exclusively contras ting with licensed contractors to construct the project (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or'improves thereon;"and who contracts for such prorecis'with a contract or(sf: licensed pursuant to the Contractor's License Law). ❑ I am exempt under Sec. B.&P.C. for this reason Date Owner 1 INSPECTOR'S;: NOTES. .. 777T, w