HomeMy WebLinkAbout1592A 1593AWORKERS' COMPENSATION DECLARATION
In ejreboraffirm that
I of ve a certificate of consent to self r
y WorkerAPPLICATION FOR BUILDING PERMIT'
Workers' Compensation Insurance, -
or a certifiedco thereof (Sec.' 3800, Lab. C.)
WCPCM5241 Great American Plan 2BR COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. % Company
O^ Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
'lion deportment. T `
12=22-86 Thel.Wm. Lyon Co.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
' I COMPENSATION INSURANCE-:
(This section need not be'completed if the permit is for one -
hundred dollars ($100) or less.), ,
I certify Thai 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.
Dale Applicant
OTICE TO APPLICANT: If; after making this Certificate of
^mplion, you should become subject to the Workers' - -
,npensation provisions of the Labor Code, you must forth.
with comply with suchprovisionsor this permit shall be —..
deemed revoked.
LICENSED CONTRACTORS DECLARATION - - -
I hereby affirm that I am licensed under provisions of Chopter9
(commencing with Section 7000) of Division 3 of the Business and _..
Professions Code, and my license is in'full force and effect.
276801 B-1,`
license Number - Lic. Class
The'Wm. Lyon -Co. . 12-22-86
Contractor Date
I am exempt under Sec. - -
B.BP.C. for This reason
- - Dale: -
. _ Signature _.. _ _... .. .. ...
OWNER -BUILDER DECLARATION
I hereby affirm That 1 am exempt from the Contractor's License
Low for the followings reason (Section 7031.5, Business and
-Professions 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 contractor 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. 31747, Civ. C.).
Na
Lender's me
Continental Illinois Bank
8
Lender's Address 231 -So. i-
So.l.a_ Salle St., Chicago
iv I.certify that I have read this application and state that the _
above information Is correct. I agree to comply with all County
g o+rces��d 5 o aws r ling fo building construction,
nd eby auf Drize repres Lives of this County To enter
FOR APPLICANT TO FILL IN
BUILDING .7 C
ADDRESS O�OOQ D L •
,
BUILDING
ADDRESS 20807 East Can on Rid a Road
-
Walnut 91789
CITY ZIP
LOCALITY
- - -- -NO OF BLDGS. - -
SIZEOFLOT 3,800 -SF Min. NOW ON LOT 0
NEAREST -
CROSS ST.
TRACT 43760 BLOCK LOT NO.
ASSESSOR
MAP BOOK
PAGE
'
PARCEL
OWNER -THE WILLIAM LYON- CO. No833-3600
usE ZONE
-
AN d
r
'..
ADDRESS19 Corporate Plaza- '- '- - - -
SPECIAL.. ..._. ... _..
CONDITIONS
_. ...
Newport Beach, CA 92660
---
-
-- -
CITY ZIP
ARCHITECT OR TEL.
Hales 547-0862
DISTRICT
G OUV
TYPE
FIRE ..
PR CESSED BY -
ENGINEER -Langston NO.
-
. _
CONST.
--
Z/O�N
,
ADDREss777 S. Main St. Ste. 105 Orange
-� 7�.
Same AS Owner TEL'
STATISTICAL CLASSIFICATION
APT.
CO
NO.
CONTRACTOR NO.
--LTC. CLASS NO. Dd. DWEIL: UNITS
ADDRESS NO.
SEWER MAP
-
- .. LIC. -
CITY CLASS
BK. - PG. ---
---
" VALIDATION
SQ. FT. NO. OF OF
CHECK
_ _NO.
SIZ STORIES FAMILIES
ONE
VALUATION _... _
.. _.
DESCRIPTION OF WORK.._ _ _ __.....,... .
NEW .. ®S
ADR-
Single familyhome construction
REPAIR . ❑
DEMOL ❑
$
FINE AL •y T
.. DAT -7 /
- - -
•- l 59.2A
- - - - -- -
It .• • 2 1
1 •247,2:3
USE OF
EXISTING BLDG.
APPLICANT TEL.
PRINT The William L On CQ •NQ. B 3- 00
ADDRESS
FINAL, L
by
-
PRESENT
BUILDING
ADDRESS
-
-
I 2.31 —86
,•
S 9, J P.
LOCALITY
MOVING TEL...
CONTRACTOR NO.
_
.-.. _-..
.,
r'.i
-V-426,00
n
e (j '2 f• 0 U 2
12 J 1- 6
ADDRESS
REQUIRED YARD -HWY TOTAL SETBA K _ ..
SET BACK PROP. LINE WIDTH
FRONT
SIDE;.,
P. L.
LDMA Ref. M
_ ...
-
"
^L`J'ylJ
P.C.fee E � � . � Permit Fee � -
Issuance Fee • ✓ CJ -
LDI P/C. �/ •/ �
-- - - -
Invesngation Fee
Total Fee -
-LDMA Perm. M
-
- - '- -
po the ov • entioned ro erty for inspection purposes. -
a N
L
X
V
SE
Z— ' E REVERSE FOR EPAATORY LANGUAGE
� j
- Signature of A�Iicant or Agent Dore
PLANS TO APPLICANT INSPECTOR'S NOTES
OWNI'.R•BUILDER,DECLARATION
.. _
I hereby affirm that I am exempt from the Contractor's
10:
Returned - ,. -
license Low for the ,following reason. '(Sec,`7031.5)
-
- Approved
Business and Professions Code: Any city or county wbicb
No. Dote
' No. Date
requires a permit to construct, alter,' improve, demolish,
-
or repairany slraclure. prior to its issuance, also requires
-'II... -. , ..
the applicant for such permit to file a signed statement
lbat he is licensed pursuant to the provisions of,the Con-
.t
tractor' License Law (Chapter 9)(commencing with Sen
tion 7000) of Division 3 of the Business and Professions
.
Code)or ?bat be is exempt therefrom and tbebasisfnr the
alleged —plion. ny violation 31.5 by
_-'Required
' - -Dote Received ---- ---�- --- - --
any appfitaniJorap�rnrit subjects the app/�ant�oacivil
Approvals
No or Approved < 1
- penalty of not more lean five hundred dollars WOO),).
.
- - -- - - - - - -
❑ I, as owner of the property, ar my employees with
Water Certifica_ to
' -� - ._,
wages as their sole compensation, will do the work, and
_
-- - _
- _ _
the structure is not intended or offered far sole (Sec. 7044)
Health Department __.
_ _ - _. - - _.: - _ - - - - ... _ -.. .. _..._ _. ._
Business and Professions Code: The Contractor's License
::: .: � ; •-.. ;. -, - - '.
Lau, does not apply to an owner of property who builds
Fire Department -
_ . -..._. - - - - - - - - -- --
or improves tberean, and who does such work bimse%or
through his own employees, provided that such -in,-
prot—tents are not intended or offered for sale..
I-
however, the building or improvement is sold within c.
Geological --,
- - _ •--�-, , •.--
year of completion, the owner-builder will have the
burden of proving that be did not build or improve for
Pedestrian Protection
-" - � ' �' - - '� -
the Purpose sale). - - ='•
p p /..
(Fence) (Canopy)
•, .• - - ---- - - - - - - ---- -- - - - - .. _
❑ 1, osownerof the property, am exclusivelycontroc-
ting with licensed contractors to construct the project (Sec.
Special Inspection' "-
- - - -
� - �-� - - -- - - ��- � � -;-��1--�- ---�- --�, - - -- --"-� - "`
7044 Business and Pro
), fessions.Code:.Tbe Conlrartor's
(Conc.) (Masonry) (Welding) - - - - ._ -- _.
-- -- --
---
License Lou, does not apply to an owner ofproperty who
-------- - - _
builds or improves thereon, and who contracts for such
Lot Drainage
I'-tel \ i�._ -. .._
projects wilb a conlract r(s) licensed pursuant to the
Contractor's License Law). -" -- - - --- - . - -'
Parking
__.._.
❑ 1 am exempt under Sec. , B.&P.C. for this
-
reason
Date _.Owner..__ -
Approvals "
Date Inspector's Signature
-INSPECTOR'S NOTES
Location—
'
(Setback 8 Yards)
Foundations
-
Slab
Frame
Energy Insulation
- -_ .. - . _' ___.._.._;_. __' .•
- .. , . - .
Lath/Drywll—
a
-
Interior I
Lath—Exterior
House Number—
Correct 8 Posted-
- r
Final--
Enter on Front