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HomeMy WebLinkAbout1540A 1541A 4 � WORKER5 COMPENSATION DECLARATION � � � � � c� a I hereby affirm ihat I have a certificate of consenl to sel! e ' Pr � �Fr � R $ insure,or a cerfificate of Workers'Compensahon Insuronce, A�����-�����-� ■ �� �%�,� ��D ��� �i��� g or a�certified wpy ihereof(Sec.3800,Lab.C.) �`-� '" � - � ' � � � - � ��� � COUNTY OF LOS ANGELES : BUILDING AND SAF6TY PolicyNo 7634-817�mPa„y . Pac. Iridemnity_ �� -:Certified�,copy is��hereby fum�shed: .':, FOR APPLICANT TO FILL IN eui�oiNc ����� j/ n� j�+_ p ADDRES$ /7-LC� i�vT-y_,s�� � �Cartified mpy is filed with ihe munty building inspec- � �RUILDING � - � � ��- tion departmeni. ADDRESS ��77 22879 Hilton Head Bld . 24��� �.�� oare Appi;�a„r S.McGinnis ��Ty Diamond Bar Z�P 9ll65 LOCALITY ` NO.OF BLDGS. '. NEAREST ' � CERTIFICATBOF EXEMPTION FROM WORKERS' - �-"" � � � - - -- �- � � -- � COMPENSATION WSURANCE size OF tOT NOW Otv i0i Q ' Ce055 57. � (Th�s�section'need not be mmpleted if the pe mrt�s for one ASSESSOR , � hundred doilars($100)or less.) 1RACT BLOCK LOT NO. MqP BOOK PAGE PARCEL TFL �gF�ONF MAP � owNea Ahmanson Dev. Nc$188147152 �j' .-�cL° � 1 cerhfy that in theperformance of the work fo which this NO. ' � � permit is issued I shall���not employ any person n any manner SPECIAL -� so�as to become�sub�ect to fhe Workers`Compensafion Laws. AODRE55 1 �l COItII11E D CONDITIONS �_� � Date . :�. .�. APPlicant . . � - : CITY . ' ZIP . � �.y� NOTICE`TO`APPLICANTr if,�after makin fhis Certificpte of � ARCHITECTOR TE�,� DISTRICT GROUP tYPE FlRE PROCESSEDBV o EXempiian;'-yoU sfiould beCome 5ubjeCl to ihe Wofkef5' ENGMEER Bb'E En�'. �j�L3Z545�-3�i' �� NST. ZONE �(,~,) �� Compensotion provisions of the Labor Code,you must forth- qDDRE55 � �d � --�d � gwith�comply�with such provisions or this permit shall 6e � ! deemed.revoked. �-. � TE�� STATISTICAL CLASSIFlCATION APT. CONDO. ,-� � � corvrencroR Ahmanson llev. No7148371279 r�� _ LICENSED CONTRAQORS DECLARATION ���, CLA55 NO. . DWEIL UNITS j I hereby affirm ihat I am licensed under provisions of Chapter 9 A�oRE55 23$6]. $1 TOYO No. 465688GB� � (commencing with Secfion 7000)of Division 3 of ihe Business and El TVTV - �'�� B-1 SEWER MAP � � ` Professions Code,:and my license;is in fu11 f6rce and effecL CITY CLA55 BK � �. VALIUATION _ Sq.FT. NO.OF NO.OF CHECK � i L¢ense Num6er���4h$�E7$B�sBC�-�;Lic.Class�-'B-1` � ��� slzE�-� cgDO STORIES - ���FAMILIES�� LF oNE �. . " ..� . � . YALUATION .. .� ��.:li I- I ' ' �' -- OESCR�PTION OF WORK � NEW � � Contractor Ahmancnn Dav_ Date j ���� � .: � : ADD � ., r��` ��� i �1 am e:emp�under Sec CARPQRTS airert Q ���a e?{):tt 5 6.8P.C.for this reason aEPAiR � s I� USE OF DEMOL "_. _._ - ' � .� F h('z � � DaYe: � - �., .� �� EXISTING BLDG. Si nature APPUCANT TEL � 1 . 9 (PR�NT)S.MCG1RI115 NO�]1�Fg61Z311 FINAL �-� L'7 Y (��J:. OWNER-BUILDER DECLARATION - DATE ,�'.G - - � � I hereby affirm that I am exempt from ihe Contrador's License - - , : � , Low for rhe fotlowing reoson�(Section 7037.5, Business and AODRE55 2290n �O].a.P_ri SpTirigS D7�7IDOttC�. �7. FINAC�' (/�� - � � ' Professions Code):� � - - . .. . . ... ._ PRESENT . .. . . BY .,. ��lJ�',��.;,_� . ... .. . �. .� I, as owner of ihe ro ert or m bUH�ING �. � � � p p y, y employees w Ih ADDRESS .;;� `�j���� ;,_: . wages as iheir eole compensation,will do ihe work and �� - - -�� � �� ihe structure is not intended or offered for sale(Sect�on ���A��T� , 4 :��a � ` . .. ..7044,8usiness and Professions Code).. . .-�-- MOVING. .... .. . ....... . .. ... . ...TEL� - r_ ._. _ . _ .. _ . ._:._ ._rr. ° ° s m._� _.� � CONTRACTOR NO. ... � I,as owner of the property,am exclusively contracting - ��t p W f�9 j� � �- - �- - with iicensed contractors to mnstruct ihe pro(ect(Sec -�-�---� AOORE55 ' � '� � � tion 7044,8usiness and Prafessions Code). �„_� q h ;�{s- CONSTRUCitON LENDING AGENCY � SET�enc� YARD HWY TOTAP OPACNEFROM yy�DTH � � � I hereby affirm that ihere is a construction lending agency tor . FRONT - L�,',''�i����,�j � �he performance of the work for which this permit is issued -- �� c.t.� �: -� - � - � -�� (Sec 3097,Civ.C.). � SIDE � . � . w _._ .._. . P.L : •,. , �. lender's Name ttOtte - � -� � - LDMA Ref.#i - - . ` � P.C.Fee$ ��', 7erm t Fee �I'� , Lender's Address � � i certify that I have read ihis application and state that the . issoa�ce Fe� 1���� v tonna.P/C# � - - m above information is wrrect.I agree to mmply with all Counfy � Invessgotion Fee / �7 y . ordinances and State laws relating to building,consiruction, .,,, iotal Fee `E'�' /`S LOMA Perm.H - �: � "' and hereby autharize representatives of ihis County to enter _ u � upon ih ove-me Yi ed propert inspecfion rpo s - , �. . �� � 3; --- _ _ _ _ _ __ _ __ h ��,�JQ � p a �� SEE REVERSE FOR EXPtANATORY LANGUAGE � � . Si9nanre of Applicam or Agen te - - '�� � 2 .� p o ,� _ � -o G> � m o � o C1-a cTn�m m � m Q m . � , rn -� CP Q (P o F � 7 t�i n-� p j � T n . 7'^. O o n � t�D � � 7 Q'n. tp � n Q J Q � � � -�p � 'O .. � , � s S �a m n. o o D 3 �� f�� ° , a '^ '� p `� ° in � � � o K °. 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