HomeMy WebLinkAbout1544A 1545A ' . � WORKERS'COMPENSATION DECLARATION - �I�
' he��°Y°"��m'"°" h°°e°�e�';`��°te°`�°�Se�„°Se" �PPLIC�►TION FOR BUILDING PERMIT ��
insure,or o certificate of Workers'Compenstion Insurance,or
a certified copy the�eof(Sec.3800,Lab.C.; COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. 7h"�li—RIQ,�npanyPar Tnrl�mnitv BUILDING �
� Cerrified mpy is hereby fumished. FOR APPLICANT TO FILL IN ADDRE55 ��� �
� Cer�ified copy is filed with the caunty building inspec- gUILDING
ro�depa���.,a�r, AooRess IF76 22579 Hilton Head Blvd. 24 iocaurv ��• �
Diamond Bar. 91765 "EAkEST
Date �ApplimN � �(`�j�c CITY �ZIP CRO55 Sl.
CERTIfICATE OF EXEMPTION FROM WORKERS" NO.OP BLDGS ASSE550R �
COMPENSATION!NSURANCE SILE(JF LOT NOW ON�OT O MAP 800K PAGE PARCEL
(This section need not be completed if ihe permit is for one USE ZONE MAP �. ��a/�
rRacr 3634h B��cK ioT No. No. � _� Y
hundred dollars($100)or less.) �. .
- TE!. SVECIAL a
owiuea �hranson Dev. No 8188147U ; corv��iiorvs
I ceriify ihat in ihe performance of the work for which�his - - � �
permii is issued,I shall noi employ qny person in�ny manne� DISTRICT GROUP ?YPE . FIRE PROCESSED BV
so as to.become subject lo ihe Workers'Compensution Lows. ADDRE55 1001 Commerce Dr. 9� CONST. ZONE �
arr Irwindale ZiP 91706 � �
Dafe__ A�p�icanf ST/sT15TICALCLA551FICAiION APf. C �O. '(„)
NOTICE TO APPLICANi: If, after makinq this Certificate of ARCHITECI OR TEL �y � -
Exemption, yo� sbould 6ecome subjeci to the�Workers' ENG�NEEH B&E ER . No.2132$�FrJI.3 CLASS No. "'�� owElL.uNlTs �_
Compensatiun provisions of}he Lobor Code,you musi forih- �DURCSS 825 Colorado Blvd. LA 90041 SEWER MAN -�
with tomply with such prcvisions or ihis permit shall be
deemed revoked � T`�" RK. PG, VAIIDATION
coNrRacroe Ahmanson Dev. No71 2
LICENSE9.CONSRACTORS DEClAR,4TION iIC
. I hereby affirm ihat I nm licensed under provisions of Chapter 9 H�DRESS 23861 E'1 TO�CO Np.�+�]56�$G73C- VALUATION �a �'�-���7 .
fmmmencing with Seciion 7000)ot Divislon 3 of the Business and - �;�
Professions Code,and my iicense Is in full+orce and effecL CITY E'�- TOTO C�q55 B-1 $ �� � ��s � � u�'� �
SQ.FT. NO.OF NO.OF CHECK �--- �
License Number4�5(�R$(;RC; Lic Class R-1 � s¢[ $�� SroRIEs FAMILIEs 4 oNE i o- ¢-�(;.�4
Q �.
Conrractor �s�;:,,...��Daje � oescki�TioN or woeK ��X���������� NEW � � - n u��j�{;,vF 9= �
� � CARPORTS ADo �
I am exempt from ihe licensiny requiremenis as I am a � �:
licensed orchitecl or a registered professional engineer --- ALTER � ���-�FINAL ��c'"��, - �1 /�� f%'-�J
acTing in ny professional capatify (Seclion 7051, � REPAIR � DATE '�' �f-
Business and Pro�essions Ccde). USE OF DE�AOL ❑� F�NA� -
EXISiING BLDG. �( n
Lic.or Rea.No. �.�..Date APauCAN? TEL 8y "I,J�`:"�`J �. . - .
—- S.?�IcGinnis 714861231
� OWNER-BUIL�ER�ECLARATION I�RWT� NO.
I hereby offirm rhat I am exempt from the Controctor's license 22900 Golden Springs Diamond B � ' �(��f,
Law for the tollowin reason Section 7031.5, 8usiness and ADDRESS �
Professions Code�: � ( PRESENT ��u �- ��- �g � � � �
� BUILDING {�
� � I, ns owner of Ihe property, cr my employees with ADDRESS � � i m �b�,7;�
wages as iheir sole compensation,will do the work and '
ihe structure is not iniended or offered for sole(Section LOCALiTV � � g��� ��� .
7044,Business and Professions Code). MOVING 7tt, � , �
❑ CONTRACTOR _ _NO. � � ,
I,as owner of ihe property,am exdusively mnirncling Q�],� �'!—,S],J�
with licensad coniroctors to consYruci ihe project jSec- ADDRE55 �
tion 7044,6usiness cind Professions Code). - -
RE�UIRFD TOTAL SETBAIX fROM E%IST
CONSTRUCTION LENDING AGENCY SET BAIX YAftD HWY pkUp �iNE WIDTH
I hereby affirm thni there is a cons`ruction lending c��ency for � - i-t20NT �
ihe performance of the work for which ihis permit is issued P.L. _ - .
(Sec 3097,Civ.C.). SIDE .
P.L.
Lender's Name ll011E9 ._.__ .
f
� Lender's Address v.0 Fee b �Lf- Per n�i Fwe �
I certify thoi I have read ihis applimtion and state that the Issu :e Fee y p`� � � �
Qabove information is w�recl.I agree to comply wiih a�l County � I�oes+�iga+�on Fee �� 7 �' . �
$ ordinonces and Stote laws relahng to building consiruUion, Total Fee �f° /� _
and hereby authorize Kepresentalives o is County to enier
.� upon Ihe e-mentio proper y r� spettion purpos . � .
p ��„4,.�'--��� SEE REVERSE FOR EXPLANATORV LANGUAGE � � �� ' ��
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