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 � � � �
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