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HomeMy WebLinkAbout1066 SUMMITRIDGE DR (4) PLAN 500BR�='" � � � � � WORKERS'COMGENSATION DECLARATION � �� • � - I.hereby�aifirm ihal 1 have a ceriificate of consent to se�f � qpp�fCATIQN��FOR BUII�.DING� �PERMIT � insure,or a certificate of Workers'Compensation Insurance, or a ceriified copy thereof(Sec 3800,Lab.C:) COUNTY OF LOS ANGELES BUILDING ANp SAFETY PolicyNo.YWCC2S3S"L�a�ony INA � � Cert'rfied mpy is hereby fumishe FOR APPLICANT TO FILL IN eu�t��Nc pP�� � v �� AODRESS / �� Cerr�f�ed copy�is filed.wirh ih c r ldi i pe eWLDING 1066 Summitrid�e Drive �� tion departm nt.�� � ADDRESS g Date�u � Appiimn CITV Diamond 73ar zia 91765 LOCALITV � CERTIFICAiE OF EXEMPTI FR ORKE 5' SIZE OF LOT NOW ON LOT '�' CROSSSST. COMPENSATION INSURANCE � (Th�s`seUion�need nat be<ompleted if the�permit is torone 42577. � / n55e55oe hundred dollars($100)or less.) _ TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL U E ZONE MAP I certify thot in ihe performonce of Ihe work for which ihis OWNER N . - 'j N� ��i • ��(�"} ,. a, �� SPECIAL g' permit is issued,I shall nol employ any person in any manner qDOREss P'�'BX..3S0 �,y� �J� CONDITIONS v so os to bemme subject ta the Workers'Compensation Laws. �re' Appl�mnr aTv Brca, CA ziv 92622 0 ��OTICE TO APPLICANT: If, after makin this Cerlifimte of !RCHIiECi OR TE�� DISTRICT GROUP TYPE PBE PROCESSED BY � g ENGINEER L.C.Majors S� ASSOG,p HEZ-HZ��I �pNS 20NE Exemption, yoU should become subjetl to the Workers' � Compansation provisions of fhe lobor Code,you must forth- qDDRE55 ZOII41 S.Paramount Ave., Downey �� -:.:5 �... � Z"e' � with tompfy with such provisions or �his permit shall be TEL STATISTICAL CLASSIFlCATION APT. CO DO. � Z deemBd revoketJ. � CONTRACTOR Owner NO. LICENSED CONTRACTORS DECLARATION �� - ���, CLASS NO. � DWELL UNITS I hereby affirm that I om licensed under provisions of Chapter 9 ADDRESS NO. (commencing wi�h Section 7000)of Division 3 of the Business and ��� SEWER MAP Professions Code,ond my li<ense is in full force ond effecL Ci7v CLa55 BK �� � VALIDATION - � SQ.FT. NO.OF NO.OF CHECK LicenSBNumber 54648 �it.Class B�- SIZE STORIES 2 FAMIUES ONE . VALUATION <O C�.���.� !i �� ,��f �'� -� �ESCRIPTIONOF WORK New Single Fami1 NEw ❑ s ��� ��,� Coniracfor_ oie A�D � , ��n ,� „ _•� with attached garage. < ❑I am exempt�nder Sec. ���"�'� � � - ALTER 8.&P.C.for ihis r� REPAIR ❑ s I Q L��1��,�v � . USE OF /-' EXISTING BLDG. N A DEMOL ❑ ^ "���I.ii C;� SignafUre_ . APPLIUNT iEL FINAL • , �,,,p� R(81J# �E DEC RATI PRINT� NOS2�i-8170 DATE t L��'-��'-�� ���� ���� - I here6y affirm iTiat I am exempt from ihe Coniradar License P.O.I3ox 350� Bx'ea� CA 92622 �° for the following?eason(Secfion 7037.5,Business and ADDRE55 FINAL f 4ofessions Code): - ' PRESENT By ��•f�. •�.; � � BUILDING ���j ��� �� I, as owner of ihe property, or my employees wilh ADDRE55 _ wages as}heir sole compensation,wil I do fhe work and , the structure is not inteoded or offered for sale(Seciian LOCALITY �y;� e e u s � ' ' 7044,Business and Professions Code). �' MOViNG iEl. � QI,as owner of the property,am exclusively conlracfing CONTRACTOR NO. � ��: '� :�i� wilh licensed contmctors to consiruct the project(Sec- qDDRE55 � � �,�p • � s . tion 7044,Business and Professions CodeJ. � j -.;j O,.> REQUIRED TOTAL SETBA K I T. �� �� CONSTRUCTION LENDING AGENCY SET&4CK YAR� HWY PROP.UNE WIDTH �R .� �._��� I hereby affirm thpt ihere is a mnslruction lending agency tor FRON7 ' �the performonce of the wark for which this permit is issued � v.�. � � � (Sec.3097,Civ.C.). Sioe P.L. Lender's Name N0112 P.0 Fee$ /J �� Permit Fee �•'C`�� �DMA Ref.# ``, Lender's Address , ..J cerfify thot 1 have r ad this applicafion and state ihat the Issuoncc Fee ����•- LDMA P/C q � a above information is rect.I agree to comp ith all County inves�igmian Fee �. ordinon and e I ws relating i g consiruction, Totol Fee � �r LDMA Perm.# and �e rize epre i County ro enter � � up th -menti ne o f pettion purpos ���,{� �-pG �_�x:,> � �/�� ��''� SEEREVERSEFOREXPIANATORV LANGUAGE igno+ure nf plimnl or eni Dnte ' � n� \ � � __ o 0 0 0 � �' v' o �n° o o i��' �m Gl G) _^ x � Z -� m o , c s 's � � o- � `=Q -^, ,r � c�o �a o o c�' o ❑ o 0 � �\ �p �-. Jt,i �. p 3 n � W o p- p -�, O � _� m ;p � �G � p F O � � � v 4 :D � � � � �- 3 Z x .�.� _ _ 7 -p �' --- �p . 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