HomeMy WebLinkAbout1496A 1497AWORKERS' COMPENSATION DECLARATION
f hereby affirm that I have a certificate of consent to self _
insure, Rr a certificate of Workers' Cornpenstion insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Policy No 7634-8118ompony Pac-,. Tnd mni v
Certified copy is hereby furnished.
f7 Certified copy is filed with the county building mspec-
L-� tion department.
Dote Applicant S.MeGinnis
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 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 L.
Date Applicant
NOTICETO APPLICANT- If, after making this Certificate of
Exemption, you should became 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
hereby affirm that I am licensed under provisions of Chapler 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 465688GBC Dc. Class B-1
. Contractor nt,;.,...,g„r n,,,, Date
I am exempt from the licensing requirements as I am a
- licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No, Data
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 703L5, 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,asowner 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 representatives of this County to enter
upon 1 above -ma typned pro r17 far inspection purpor�3.
ti G
Signature of Apcft ant or A ent ate
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRESS % 4
fah-� 4, `
BUILDING
ADDRESS Bldg. 23 22875 Hilton Head Dr.
LOCALITY
CITY Diamond Bar
zip 91765
NEAREST>
CROSS sT
NO. OF BLDGS,
ASSESSOR -
SIZE OF LOT
NOW ON LOT 0
MAP BOOK PAG[
PARCEL
USE ZONE
MAP }
TRACT 36346 BLOCK
LOT NO._'
',r
NO. /�`
-' 1
OWNER Ahmanson Dev.
TEL u �<1+'!
NO.8188 L47152 Of'i%L%
SPECIAI.
CONDITIONS
DISTRICT GROUP TYPE
FIRE PROCESSED BY
ADDRESS 1001 CominprPis.
Dr
CONST,
I
700NNF,_
A" "C
CITY Irwindale
ZIF 91706
-
ARCHITECT OR
TE
SIATiSTKAL CLASSIFICATION
N
APT. CODO.
ENGINEER B&E Eng.
N�132545134
CLASS NO, 0 YDWELL. 1 NITS
ADDRESS 825 Colorado Blvd. LA .90041.
SEWER MAP
'
CONTRACTOR Ahmanson Devel. NL .7148371279
BK. PO,
VALIDATION
ADDRESS 23861 El Toro
No- 465688GBC
VALUATION
CITY El Toro
LIC,
CLASS -
$ 294,630
1 4 c, 6
MFT, NO OF
7392
NO.OF CHECK
8
SIZE STORIE52
AMILIES ONE
li a -2 u 2 1
DESCRIPTION OF WORK Condo
NEW
s
i s 6 6 �i, 2
"A Tr
ADD Q
..AVER [
FINAL -
s « -,r. /I,.9 2"
REPAIR E]
DATE
�' bDE
USE OF
EXISTING BLDG,
F t'
MOL LJ
FINAL (
Rv
22900 Golden Springs Diamond
®MOVING TEL 0
REQUIRED TOTAaoSETpBAOC FROM FXIST-
cr. anry YARD HWY ,� � Inru
SIDE
PI.
P.C. Fee $ w C^ '] • ,/y Permit Fee
Issr a Fee
Imesugation Fee an
Total FcaC�-
4�✓Ji 911 & Y
SEE REVERSE FOR EXPLANATORY LANGUAGE
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