HomeMy WebLinkAbout1540A 1541A (9) 4
� WORKER5 COMPENSATION DECLARATION � � � � �
c�
a I hereby affirm ihat I have a certificate of consenl to sel! e ' Pr � �Fr
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$ 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 � � .
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