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HomeMy WebLinkAbout1546A 1547A (9) WORKERS COMPENSATION DECLARATION - - .� � I hereby affirm fhat I hqve a certifimfe ot consent lo self ��.�LIC�T-ION FOR BUI-LDI-NG PERMIT insure,or a certificate of Werkers'Compenstion Insurance,or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY P❑ol�icyNo.7Fi4la-R11RCompany j�aC Tn�jeIDni{-��� BUILDING lj �p..� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN .��t� J ld�..• � ADDRESS � Certified copy Is filed with ihe county 6uilding inspeo- BUI!DING ,� nor,d�parrmeot. nooRess Bld . 24 22879 Hilton Head 4k75 �ocnurv .�i.MCU'I11111S NEAREST oa�e npp���or,r c�rv lliamond Bar zia 91765 ceoss sr CERTIFICA7E OF EXEMFTION FROM WORKERS' NO.OF BtDGS /+SSESSOk COMPENSATION INSURANCE 517F OF LOT NOW ON LOT O MAP e00K PAGE PARCEL (ihis section need not be completed if rhe perm�t is for ane � USe ZONE nna.a hundred dcllars($100)or less.) TrtACT 36346 etoCK �o�rvo. No. �, Te�_ svecini � I cerfify ihat in the.performance of fhe work for which fhis OW�ER N �OND;TIONS �� permii is issued,I shall noi employ any person in any manner DISTRICT GROUP�TYPE ' � FIRE PROCESSED eV y� so as to become s'ubjeci to the Workers'Compens�fion Ldws. ��DRESS. 1(�Q171�..OI1llIl2TCe�DT. . 9� CONST. ZONE �., ( � �iir Diamond Bar ziP 91706 � Date —Applicant— - SiAiISi�CatcLA55�F�CAtlO AGi. C o0. ty NOTICE TO APPLICANT� If, atter making this Certifimte of � ARCHITECT OR � TEL. .�� Eyq Exemption; you should beceme s�bject !0 1he Workers' ENGINEtR NO. CLA55 NO. DWELL.UNITS_ � Compensaiion provisions oi ihe Labor Code,you rr usi fo�ih- ADURESS SEWER MAP � �ith <cmpiy wi+h such pravisions or this permit sholl be � deemed revoked - � TEL AK PG VALIDATION . CON7RACTOR - NO. ucFNseo coNrRncTORs oeanRanoN 23861 El Toro ���' 465688GB I hereby affirm thal I nm licensed under provislans of Chapfer 9 � AnDRFSS NO. VALUATION `:� r,_� r.� . (mmmencing with Section 7000j of Division 3 of fhe Business and El Toro iIC ,_(�� � .- ` F Prnfessions Code,nnd my license is in full force and effect C�.�v C1.4558-�- $ C�'' .. . . Sc�-rT No.oF n�o.oF �Ht�K �.e s � R�'� u�e�se Nombe� 465688GBCu�.aass B-1 size 800 siowes FnMnies 4 orvE (' ConitoCfor Ahmanson DC'V. pQ�e � DESCRIPTION(JF 1NORK ��(25Et" NEW � $ I �' �J Si����'% � CARPORTS ADD � a � r u��:t=S U I pm ezempt from ihe�kensing requiremen�s os I am a licensed architect or o registered professional engineer ALTER � FINAL {���� � �,.� �,��. ading in my professional capaciry (Section 7051, ❑ DATE �" REI'AIK 8usiness and Professians Code). � USE OF pE��n� ❑� p�ryq� - � ' ExISiING BLDG, � BY �fl,��. Vl Gc.arReg.No.__ �__�oole._ — � HPP�P�1N7j S.MeGinnis ���148612311 '� OWNER-BUILDER DECLARATION . I hereby offirm that I om exempt from ihe Contractor's License � qDDRe55 zZ9Q0 GO�.C12R Springs Diamond B Lqw for ihe following.renson(Section 7031.5, Business and � z 1 C%'`d 1 �i � Professions Code): � ` ppe5 N � � � �, as owner oi the property, or my employees with AODRESS � � �� 0 � �,° f ages as their sole mmpensarion,will do the work and � ihe 51ruUure is not intended or o(fered for sale{Section LCCALITv i ��°E i.��:� 70�4,Business and Professions Code. � MOVING TEL. � � � I,as owner o{the property,om exclusively mnfracfing � CONTRAC70R NO. � �@ � a:�% �. ! u[: � with licensed wntradors to construct ihe project(Sec- ��on 70A4,B�siness and ProFessions Code). t ADDRESS ('� � q-�'�� RcQUIRED TOTAL SETBACK FROM EXISi CONSTRUCTION LENDMG AGENCY ser sqCK YAkO H`mY pROP.uNE .wiD7H� - I hereby affirm thot+here is a consrruuion lending agency£or �RpNi - -� � the performance of Ihe work for whlch this permit is issued a.L � (Sec.3097,Civ.C.). SIDE . . ' , p.�.,. � . Lender's Name _ � �f� � ; Lender s Address � �, P.C.Fee F ��* Perrnh Fee � . - � , I certify thai I have read this application �nd state ihat the Issu e Pee `�°"'b V � , -above infonnation is corract.I agree to comply with all County �� Invevigation Pee �� . ordinances and State I�ws rel�ting to building consiru:ticn. � Tr.rolnhee ��- /�� � � and hereby outhorize rep�esenralives of ihis Couniy to enfer . . . � � upon the bove meNio,}ne properry nspection yrposc. 6 � . � � � r����_D,_T��L./ SEE REVERSE FOR EXPLANATORY LANGUAGE � � � � �s����".E8' / ' Siynat�re f App ca ge ie � - �s � � o � c T � g , -o o �e-�-o rn Q m Q � � Q o, � .e.-- r +Tc � ?' ua o � n 7s'' t�7 o Q c�N, .�?' `ca � � �' � . . `("" 3�, o o a a � 3 � 2 Q o' �,. `s� �� ✓� C�Q Q 3 �' � � a a �� Q � � ° �� g : N 5 �`� � fD A F-7 ,�.� � w N O O s � N 49�„ � O � �� K �� � 3 �I S � ? n• � � 3 °� ; � �Z � ^Q G N � 0 �a .^ r i� O -6� � � � 3 j �" . � o � � � ' C �' � � � � S � 7 �'�� Ca': p '� � �' .!' 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