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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 � - Signnrt�-eo Ap canlorl�g-nf � ate � ' � . �s - � � _.:.----;�`� � � � g � � �� � Q .�-- �, �� � Q � � r -p � a 61- G° S Q o O l9 n w a � � C7 f� . ,Ta �Or 7r� � n Q � �� � � ':.S a. 'ffiSy'� Kb . r �, ; 1 ¢ � C 6 Q 7� �. --�? �.�Q gz 3 Q Q � � Q �,'_" n s ° °s :u � � °- ° ° � t°a fl� � � , ? 3 Q Q R^'> �.Q °c s =�. � m a, F' is ,m L � -°a � ? "' 1 � �" i �a �+ n� � � �'� ° �O .�� � o � z � w N -G q s o � &�- N �� G � � 3 . 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