HomeMy WebLinkAbout1444AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec, 3800, Lob. C.)
Policy Company St,9tc COMP. Fund
a
Certified copy is hereby furnished.
®Certified copy is filed with the county building inspec-
tion department.
Aloha ools y:
Dale 2/3/89 Applicant
CERTIFICATE OF EXEMPTION FIRCIA WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 28 9947 Lic. Class C-53
lc,ha
Contractor 2/3/82ate
aL,am exe t from the ensing requirements as I am a
licensed architect or a registered professional engineer
acting in my Prof.
ssionoI capacily (Section 7051,
Business and Professions Code),
Lic. or Reg, No. Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
1, 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
lender's Address
? 1 certify that I have read this application and state that the
°C above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes,
a �Si
icant r Agent ote
FEB 0 8 198Z
APPLICATION FOR BUILDING
PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING 2176 Rocky View Rd .
BUILDING
ADDRESS 2176 Rocky View d.
o
LOCALITY DI-ar and Bar
CITY Dizi niond Bar ZIP
NEAREST
CROSS ST. Rid�,e LaneRJ.,
NO. OF BLDGS,
SIZE OF LOT NOW ON LOT
ASSESSOR
MAP BOOK
PAGE
PARCEL
TRACT 30091
BLOCK. LOT NO. 1.27
USE ZONE
MAP
NO,
OWNER John oolsby NO.6 J7
CONDITIONS
ADDRE5513j 31 Dot Ave.
DISTRICT
GROUP
TYPE
CONST.
FIRE
ZONE
PROCESSED BY
CITY T ' t - ZIP
ARCHITECSTATISTICAL
ENGINEERT ORicha d '01oCIZ1(? NO.92 4-6915
CLASSIFICATION
CLASS NO. DWELL. UNITS
APT.
CONDO.
ADDRESS12330 Rose_ at. Cerritos 90701
SEWER MAP
) BK. PG, VALIDATION
VALUATION
$ 18,500.00 1 1 4 k 4 A
U+ a s • 23
$ ® 1 0, a
FINAL °® 1 0 0, 0 G 6
DATE (! 2 0 3- 8 2
FINAL
By
CONTRACTOR Aloha Pools NO . 962.-177
LIC
ADDRESS1701.9 E-Fr.ancisquito NO, 239947
CITY WCSt Covina CA. 91.791CLASS C-53
SQ. FT., n NO. OF
SIZE 1,o STORIES
NO. OF
FAMILIES
CHECK
ONE
DESCRIPTION OF WORK SwimnTin`' pool &
NEW tE
ADD
ALTER E]
REPAIR
DEMOL
Spa
USE OF
EXISTING BLDG,
APPLICANT
PRINT) Al-OheSl PoC,1s N0912^1779
ADDRESS!7019 ) .Franciscmito,W. Covinn
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST,
WIDTH
FRONT
P L.
SIDE
P.L.
P.C. Fee $ �� �a ..� 1`�lj
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
0
