HomeMy WebLinkAbout1415A 1416A WORKERS'COMPENSATION DECLARAT�ON .� .. �
I hereby alfirm Ihaf I have a ceniiico�e oF tonsent ta se�f .. .. - �APPLICATION FOR BUILDING .PERMIT �
'-insure,or a certi(icate of Workers'Compenstion Insuiance,or -
a cerr�fied copy thereof(Sec.3800,La6.C.)
• COUNTY OF LOS ANGELES BUILDING AND SAFETY
r�Qc,.3$5-101-391 comPo�Y Argonaut
Cerfified co is hereb furnished. BU�I�iNG �
❑ PY 1' FOR APPLICANT TO FILL IN ADDRE55 S�+O GOZ�Tl SF7r117gS Dr, (NOL'th)
k:.4 Certified copy is filed wifh the caunty building inspec- BUIIDING 5/,/, •�i01�1"1 5• S �1V� �IlUr
Idd fion departmenL - ADDRE55 �� pr�g iocaurv Di�notld Bar
� Dote� 7�1�81 Applicant �•�� �� � aTv Di��d Baz'. .... ziP 91765 ceossssr. � .
CERT�FICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR ,
� - COMPENSATION INSURANCE ' � SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL �
(This sectlon need not be compleied if�he permit is for one , USE ZONE nnnF
hundred dollors(SI00)or Iess.� TRACT� - '' BIOCK ior NoBLDC. 29 ,p3 � No. �3-.3'�� �,
' . r��+ A*m�+�,T �/��� TEL. SPECIAL . a
� OWNER il]�i CILYUL'lV VLWI/L No.599-6864 ���S� CONDITIONS
I certify�hol in the performonce of ihe work(or which fhis ^., �
permil is i5sued,I Sholl nof employ ony person in any manner 6Z WV117a B1Vd� DISTRICT GROUP TVFE , FIRE PROCESSED BY V
so as to be[ome subje[t lo ihe Workeri Compensation Laws. P.DDRESS 9. CONS� ZONE / �
�0 p� % /✓ /�QtCR,v O
c�Tv San Dim�s z�P 91773 �
Date � ' AppliCan� - ' � SIATISTICAt CLASSIFICATION � APT. CONDp.
ARCHIiECT OR .TEL�
NO�ICE TO APPLICANT: If, after moking �his Certifico�e of� EtdGNEER � O/� �1 W
Exemption, you�should become subject fo Ihe Workers' � CLA55 NO. DWELL.UNITS � n.
Compensotion provisions of the Lo6or Code,you must forfh- pDDRE55�-F76F) P2.Y�C GT�18Cj2. liG1GUaSaS ' SfVtlE4 MAP N
with comply wi�h such provisions or this permit shall be �
deemed revoked. . - . CONTRACTOR � AI`IDIN(�OUP No.599-6864 � eK. � ��c, �� � vnuonnoN .
IICENSED CONTRACTORS DECLARATION ��C. �
1 hereby aifirm that I am licensed under provisions of Chapter 9 . A�ORE55 � N0.37��. VALUATION
(commencing with Section 7000)of Division 3 of ihe Business and ��� � -
. : Professions Code,and my license is in full force and effect. . C�TY - G�ASS � E 3F)S�OOO.�� � �� ��� �l��J�� � - �- �
"licenSeNumber 3715a1 SQ.Fi. NO.OF NO.OF CHECK .
Uc.Closs B n S�ZE 8955 STORIES Z FAMILIES 7 ONE �• • • •`Z;�
CORirOf101 � � �Ur po1B-�d/"�' DESCRIPTION OF WORK� N� �J I 5 � .�� �3 6 �
� I am exempt from�he licensing requiremenls as I om o �]—P]_p�{ (',ppap � � ADD � • .'7� 7,.3 6= �
licensed architect or a regisfered professional engineer . _. . , .. ._. AITER � FINAL / �
� acting in my profe�sional capacily (Sectton 705t, � REPAiR � DATE (O /,� pZ,i 0 2�� �8 G
� Business and Profeesions Code). . USE OF � DEMO( FINAL �
� ExISTiNG BLDG. ❑ BY
Lic.or Reg.No. Do1a ... APP�vR Ti--.'�.�IN �� �No: �599-6864
' � ' � OWNER-BUIIDER DECLARATION - � ��.� � �� � �
I hereby affirm�hat I am exempt from�he Contrac�or's License ADDRESS 629 Covina. Blvd S2LL D1Sll8S � � �
_ .Law for�he following reason(Seuion 7031.5, B�siness and . �� (G�,6 A
Profeseions Code): � . � p��g�hi �
. ❑ . _.. BUILDING__ _ .. . _ . _ . . . _ _. - �• • •-�'� �
- I, as owner of the property,�or my employees�wiih- q�oaE55
wages as their sole compensaiion,will do�he work ond i�Autr � -:,\�,�. , ' t� ' f�.1.2 8 9,5 0
� the strottvre is not intended or offered for sale(Sec�ion " - - .
7044,Business ond Professions Code). nnOVwG iEL. - `
❑ CONTRACTOR ' NO. ' � ' �`� � . '� ''•� ` , • 1.2 8 9.5,0 c=i
I,os owner of 1he property,am ezclusively conlratting
wilh IicenSed contracfors lo construct the project(Set- qDDRE55 �`L�� �8 2
.. tion 7044,Business and Professions Code). � � � �� ' - ' '' . " " - ; �'� ; "
REOUIRED TOTAL SETBACK FROM E%IST. -
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.UNE WI�TH � • . •� . . .
I herebyalfirm�hat fhere is o construclion lending agency for - - pgONt ' �
ihe performonce of ihe work(or which ihis permil is issued P.l. , �
(Sec.3097.Civ.C.). . _ . . . .SiDE - . . . - •. . � � - ' .
1 �7 Continmtal Illinois P`
"131e��.aI1 a e, C3g0 1riO1S . ✓] l ' . . � , � � .
lender's Address P.C.Fee S I J• ✓ Perma iee ���� �� ,,.,�,�., .
I certiiy�hat I have reod�his opplication and state thot the issuance Fee �.,�v �
above information is correct.I agree to comply wi�h all County . invesrgm�on Fee . .. . ... .. . p . . .
ordinances and Sfale lows relating to 6uilding conslruc�ion, To+el Fee ��p �Sd
ond hereb aulhorize representotives of Ihis County to enter � �
upon ih bove-mention d property for' speUion pu�poses. � , ' , . � '
�t(,�D7 -t
!� l../ .v-tT'�t �//�� SEE REVERSE FOR EXPLANATORY IANGUAGE � ` - , " � ' ` '' ' � �`
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