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HomeMy WebLinkAbout1498A 1499AWORKERS' COMPENSATION DECLARATION 1 -hereby affirm that 1 have a certificate of consent to self insure, or 6 certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. 7634-811$ompany Pac. Idemnity Certified copy is hereby furnished. S(Sil Certified copy is filed with the county building inspec- tion department. Date Applicant S.MCGinniS CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date - Applicant - NOTICE TO APPLICANT: If, after making this Certificate of - 'Exemption, you should become subject- to the Workers: Compensation provisions of the Labor Code, you must forth- - with comply with such provisions or this permit shall- be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 700D) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number46ShRRGBC Lic.Cl❑ss$-1 Contractor Ahmanson Del. Date I am exempt under Sec. B.BP.C. for this reason Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exemptfrom the Contractor's License Low for the following 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). 1, 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 none Lender's Address I certify that I have read this application and state that the .above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize rep re atives of this County to enter upon above- ntioned ro erty for inspection pur ses. Signaturdof Applicant .,`Agent Af FULA 11U 1 -UK BUiLLANG rr.K I i COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESS L f t Z ` BUILDING {� ADDRES 2 Hi. O LOCALITY L Diamond Bar 91765 CITY LIP CRO-5SNEARE CROS$ ST. , NO. OF BLDGS. SIZE OF LOT .NOW ON LOT 0 - ASSESSOR MAP BOOK PAGE PARCEL USE ZONE MAP �'I ) 41 TRACT 36346 BLOCK LO`NO. 5 9.- /Al- OWNER Ahmanson Del. NC��f 7 i `���� SPECIAL CONDITIONS DISTRICT .GROUP TYPE FIRE AODRESS1001 Comme-irre- Dr. — CONrS'ITs Z�)�CITY Fiotc— ITWlndale LIP 91706 (t� <� ARCHITECTOR T STATISTICAL CLASSIFICATION APT. ONDO. / / ENGINEER.. B&F En N%132545134 -CLASS NO. - 0 DWELL. UNITS_ NEW ADDRESS 825 Colorado Blld. - LA 90041- SEWER MAP TEL. CONTRACTOR Ahmanson Dev. 148371279 BK. PG, VALIDATION 23861 El Toro Rd. No465688GBC ADDRESS VALUATION LI CITY El Toro CLASS B-1 $ RR 294.630 4" 1' J A SQ. FT NO Oyy NO. OFQQ CHECK 7392 ONE '= ' SIZE STORIE§ FAMILIEY ®.9.21 DESCRIPTION OF WORK condos NEW © $ ( c 6 L k 9 ADD ❑ V C ALTER ❑ FINAE f e r• 6 6 ll, 9 2 REPAIR ❑ DATE 4-D USE OF - ❑ FINAL LI i. I rJi r g EXISTING BLDG. DEMOL gv �•} i { a S.McGinnis No7148612311 22900 Golden Springs Diamond Ba 1 6 9', 9 TEL I 1: 1 C 8, '0) U.... )R NO. 8 61 YARD HWY TOTAL SETBACK FROM EXIST. U /. 1 t+ v 8 '5 PROP. LINE WIDTH L 6 " / Permit Fee ✓// IssuanceFeen fee Tocol Feat v(. �' SEE REVERSE FOR EXPLANATORY LANGUAGE - - - ®s El m 1 Q. �4-c Z CI� "31 ID ZI, cS tt zt a it Qt It R zz- T zz- 30, 't h M OU "i nz, 101 OOH.. S2 i, ZSF 'CL