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HomeMy WebLinkAbout1544A 1545A (9) ' . � 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 � � �� ' �� � . Slgno.�re of Applirant or Ngent te � � � � � T� � � � �' m � � � � � i�v ct � eo Q :� o �. r r � � � w 0 �p � F p � �. � ry Q a:. � �- �. . rn�! n S � sa � Q ca c n � •" Q m� s°. � � � m ��� o o �- co � cr � 'a' � Q. ,.. Q �, Q o � � _ c �' a Qo � � � "a� �'� ° ,u � � �a `,�° � c° ° r� � R SN fl� 3 a � � � q o �� � rn �, o l � �"4 � W Q � O � � , Z r .� 3 � � €a � o � ° ° s 3 � � .�, �''c a o$ � v i < � ^.,. 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