HomeMy WebLinkAbout1548A 1549A (9) WORKERS'COMPENSATION DECLARAT�ON � ��
' he�eby°"�rm,h°� ' h°�e°�e�f;`;�°,e°`�°°Se�r,°Se'` APPLI�ATION FOR BUILDING PERMIT
insure,or a ceriificate uf Workers'Compens!icn�nsurance,or
o cerrified copy thereof(Sec.3800,��b.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY
PolicyNo.7h4(.iT,_,__.�,.___R1lRComppny Par_ Tn[�pmniYy� �> �
❑ Pr� v FOR APPLICANT TO FILL IN noo ess �7� f+f�r R`
Cerlified co �s hereb fumished. �Z
� Certified capy is filed with the muniy bullding inspec- &UaowG �
tion deportment. ADDRESS Bldg. 24 2'L879 Hilton Head �f74 iocaurv �.,/�.
NEARE57
�Daie qPp�;�a„r S.McGinnis oTv Diamond Bar ZiP 91765 ceosssr.
CERTIPICATE OF EXEMPi�ON FROM WORKERS' - NO.OF eI�GS. FlSSESSOR �
COMPENSATION INSURANCE � SizE oF�oi NOW Otv�07 O MAP BOOK PnGE aakcet
(This section need nof he complefed i4 ihe permit is for ene . USF 70NE MAP
rRacT 36346 Aioa �or No. No 6/ — �f
hundred dollars($lOD)or less.j TE� SPEQAt . �
I ccrtify thot in the���ro�ma��e or u,e wo�k fo�wn�ct,in�s ow"ER Ahmanson Deve. No.�l$814�15" coNoinoras g�
ermii ls Issued,1 shaif noi em 10 an erson in an manner DISTRICT GROUP TYFt FIRE . P&OCESSE�BV �
P P Y Y P Y . CONSf. ZONG
so as to 6emme subjecf to fhe Workers'Compensotion Laws. ADURE55 1001 Commerce _o. �
oTY Irtaindale Zi�, 91706 �
Dafe Applicant �ATISTICAL CLASStFICAIION APT. CONDO.
NOTICE TO APPLICANT: If, aftcr makin this Certiticate of ARCHnECt OR � TEL. �¢6
Exempfion, you should become subje� fo the Workers EN6INEER -�" �x . N�]_ 2 CLA55 NO._�DWELL.11NIT5, �
Compensation provisions of ihe Lobor Code,you must forlh- ADDRESS $25 Colprado �ZVd. LA 90041 SEWER MAP - �
� with mmply with such provisions or ihis permil shall be �
deemed revoked � t VALIDATION
coNTRncToe Ahmanson Dev. N 14 837127 �K P�
UCENSED CONIRACTORS�ECLARATION LIC. � � �
I hereby affirm that I am licensed under provisions of C��apter 9 ADDRE55 2386i El Toro Na 465688GBG VALUATION
(commencung with Sectlon 7000)ot Divis-ion 9 af rhe 8usiness and uC- �' / �
Professions Code,and my liwnse is in(ull torce and effed. C�TY E'� TOT'O CLASS B—�- S � B2 �
sc� FT 800 No or No oF 4 cr+er.K �`-�� 5 li,�'P:
ucense N��nt�e� 465688GBC uc.c�ass —1 size sroeies FnMiues oNe
con�ra��o� Ahmansan Dev. oesceiPrioN oF woRk �X�L�X NFw � s #° g a P�;
Date �v�
� I om exempt from ihe licensing requiremenis ps I am a r+E1RP�RT$ � An� � ( i � e � �C�
licensed archltect or�registered professional engineer ALTER � DA E� `���l� � ° �v v-'��
acling in my professional rapacity (Section 7051, REPAIR � �
Business and Professions Code). USE OF `
� EXI$TING&LDG. DEMOL � 'BY AL �n n��' C� /� I �"'rG`v
❑�.o�aey.No. o��� aPPucaNr S.i°IcGinnis TE'- 714861231 J!
OWNER-BUILDER DECI.ARATION {HRiNT) ` NO. -
i he,ebY orr,�„rt,ar i am exem�r rrom rnP conrra�+o:s a���se , Fl�oecss ZZy00 Golden Springs Diamond Ba
Law for the fo!lowinc,�reason (Section 7031.5, 8usiness�nd �
Professions Code): � PaeSeNi - q `k
aBUILDING .�.--��� -� # S 17,��1-{
I, as owner of the property, or my employees with ADDRE55
wages as fheir sole campensation,will do ihe work and f� ,� �. � � �,
ihe sirucWre is not intended or oftered for sale(SecPion iOCA�ITY r�" � �
7044,6usiness c nd Professions Code). MOVING ItL.
� I,as owner of the property,am exclusively mntrac�ing CONTRAQOR_ _ ._ NO. � ° "���. � �5
with licensed mniractors to construcf the project(Seo- , � �_
tion 7044,Business and Professions CodeJ. A��RESS � '��' �.�J�..o
REQUIHEU IOIAL SE�BAIX FROM EXIST.
CONSTRUCTION LFN�ING AGENCY SE7 5ACK YAR� H�� PROP_ItNE �NIDiH f7 f.� Q""'�:
I herehy atRrm thaf there is a cansiruction lending agency xor PRON7 .
the performonce of the work for whith ihis permit is issued P�.
(Sec.3097,Civ.C.1. Si�E .
F.L.
Lender's Name nOR2 _ , .
P.c.F��s .�a. Ne,m�,Fee <,I, ;2—;•-
° Lender's Address-_.._._ - �
I certify that I have read this application and state thnt the - ! issuance Fee �6 r-�� - �
- a6ove informatinn�is correct.I cgree to comply with all County �� p�vesigmion Fee ��
ordinances ond State laws relating to building construction. Tc�ol Fee �
and hereby authorize representatives of this Counry to ent r -
� up� 6ove-men�oned prqP or inspection urpo .. . . .. � _
��,�� ,,.��4�+ SEE REVERSE FOR E%PLANATORY LANGUAGE
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