HomeMy WebLinkAbout1494A 1495A (8)WORKERS' COMPENSATION DECLARATION
I fimeby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab, C.)
Policy N.,'7634—Al IR Company Par. Tndemni tv
Certified copy is hereby furnished.
r"T Certified copy is filed with the. county building inspec.
LXvJ tion department.
Date Appli—I $ Mol"i—i c
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performonce 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 dt
Exemption, you should become subject to the. Workers'
Compensation provisions of the Labor Code, you most forth-
with -comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DEC[ARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7W)) of Division 3 of the Business and
Professions Code, and my license is In full force and effect.
License Number 465688GBC Lic. Class B-1
Contractor Ahmanson Dev. Date
am exempt from the licensing requirements as -I am a
licensed architect or a registered professionalengineer
in citing in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. -- __-._ Dote
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law 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 cc.mpensat ion, will do the work and
The
structure is not intended or offered for sale (Section
7044, Business and Professions Code). -
D1, 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, C- C.).
none
Lender's Name
_ Lender's. Address
I certify that I have read Jhi,, application and state that the.
aabove information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby oufho— r.pr.,e Lives of this County to enter
a upon above-ro tione -rope fly for inspection_purp s.
i2 Signature of Applicant or Age, ofe
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
ADDRESS 6ZJ COlOTRl,d,
FOR APPLICANT TO FILL IN
BUILDING7z•^
ADDRESS
BUILDING
L,
NO17148371 779
BK. PG,
VALIDATION
ADDREss 23861 El Toro Rd.
ADDRESS
Bld .24 22.879 Hilton Head Dr.
LOCALITY
El Toro
c Ass B-1
294,630
Diamond Bar 91765
NEAREST
S
CITY
CROSS ST.�^-
SIZE STORIES FAMILIES
NO. OF BLDGS.
ASSESSOR
4 ! 4 A
DESCRIPTION of WORK condo
SIZE OF LOT
NOW ONLOT 0
MAP BOOK
PAGE
PARCEL
USE ZONE
MAP
FINAL _
DATE
TRACT
36346BLOCK LOT NO. 6
3 /
NO.
SPECIAL
e - 6 6 cn A q'2 U
TEI,., e', -j07j
-'
L'EMOL
NC>P188147152
n��
CONDITIONS
TEL
C71 9 ` 9
DISTRICT
GROUP TYPE FIRE
PROCESSED BY
1001 Commerce Dr.
CONST 7.0/�)E
f
$2'
[FNGINEER
Irwindale ZIP 91706
��
✓�–!
l _f�Y'T+'
S ATISTIC L CL SSIFiCATION APT_ CONDO
OR TFIL
B&E Eng. NO 213254513
TEL,
CLASS NO.
DWELL. UNITS
j//
ADDRESS 6ZJ COlOTRl,d,
LA90()41
stwr MAP
CONTRACTOR A17manson Dev.
L,
NO17148371 779
BK. PG,
VALIDATION
ADDREss 23861 El Toro Rd.
No.465688GBC
VALUATION
El Toro
c Ass B-1
294,630
CITY
S
SQ. FL NO, OF NO. OF
/392 2
CHECK
8
SIZE STORIES FAMILIES
ONE
4 ! 4 A
DESCRIPTION of WORK condo
NEW
i
a ® a
s C. 1
`' it
ADO ❑?
,w
_ ALTER
FINAL _
DATE
( e 6 6 4, 9 C
REPAIR
e - 6 6 cn A q'2 U
USE OF
EXISTING BLDG.
-'
L'EMOL
FINAL
By �`1�
-
C'
APPLICANT
TEL
C71 9 ` 9
(PRINT)
N ?111-
ADDRESS 22900 Golden Springs Diamond Ba
PRESENT
BUILDINGS
t
1 j 91 5 A
ADDRESS
LOCALITYMOVING
TEL,
CONTRACTOR
NO.
ADDRESS
F` 1, 1 C 8, C C 5
REQUIRED YARD HWV IUTAL SETBACK FROM EXIS?.
SET BACK PROP, LINE WIDTH
_
v . O,� q
l� 1 O JC
M
P.C. Fee $ 6&4/.?z Permit hoe 107-3--v
-3--v
Ivuonce Fee
Inv Ischio Fee
Total Fee �C•'J L./ r1
ft/0
SEE REVERSE FOR EXPLANATORY LANGUAGE
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