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
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