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HomeMy WebLinkAbout1556A 1557A (9) I WORKERS'COMPENSATION DECLARATION II ! re.,y affir�rn tf-�ui i nave a certiricate ai consent to se�t � A�F LI�A�I�IV F�� �UILDING PERMIT � ( � in5ure,or a ce�tificpte of.Workars'Compenstion Insurancc,or �i a certified mpy rhereot(Sec 3800,Lab.C.j pou�yNo. 7634-811�ompany Pac. Indemnity COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ pY Y FOR APPLICANT TO FILL IN a�oRess �'��] /�c.��x. Certified m is here6 furnished. ,[. � Certified copy is filed with ihe county 6uilding inspec BUILDING ,t r�o�depa��me„r. nooRess Bldg. 24 �ocAurv {.�'�a Dale A licant S.MCCi1RR15 CITv NEAREST pp D" o r z�P 1 6 ceosssr. _ CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF RLDGS ASSCSSOR COMPENSATION INSURANCE SIZE Of LOT NOW ON l0T � MAP BOOK � PAGE PARCEL (This sedion need not be mmpleted if ihe permi�is for one USE ZONE MAP t,�nd�ed dolla�s($ioo)o,�ess.) rkaa 3b346 s�ocK �or No. No. �� —�.-�t > � TEL SPEQAL . I<arti?y ihat in fhe.perforrnance of tiie work for which ihis OWNERQ,hID2RSOt1 �2V. u0. $18g�4�1 CONDITIONS � ermil is issued,I shnll nof em lo an rson in an er DISTRICT GROUP IYPE FIRE �PROCESSED BY � p p y y pe y mann , ADDRESS � CONSI. ZONE so as to become subjecf to ihe Workers'Compensation Laws. �� 2�,$- � a;v Irwindale zia 91706 '`' � Oate— Applimnt , SiAi65TICAt CIASSIRCAllO APT_ ON�O. � _ NOTICE TO APPLICAN�C ff, after making this Certificate of � /+RCNIiECT OR TEt � Exemption, you shouid become suhjoci to the WarkPrs � Eticw[[R B&E Eri . Nc�132545134 ciass No.�owe��.uNiis_ M �Compensation provis�ions�of ihP Lpbor Code,you must forth- ,�qpDRF55 SEWFR MAP. . �' with comply with such provisions or ihis permit shall be T deemed.o•�oked. coNrenaoe Ahmanson llev. �148371279 BK. PG, VALIDATION LICENSED CONTRACTORS DF,CLARATION �iC �h��eby affi�m thot�am liwnsed���de�v.o�isio�s ot chapter 9 noosess 23861 El Toz'o No.465688GBC yALUATION (commencing wlih Section 7000)of Dlvlsion 3 of the Business and ��� ��� _ Professlons Code,nnd my lice�ue is In full forca and effect. . CiiV $1 rDTO CLASSB-�- S � 465688GBC B-1 5°EFr 800 sioa�s FaMi�Es 4 �oNeK �� ����� License Number Lic Closs , �ESCRIPTION nF WORK C3YpOTtS NEW � $ �`� R n e�� Contractnr Ahmancnn Tlav_ Date � I am exempt from the liwruing requirements as I am a AUG � 1 � a:(J.:�l C - licensed nrchitect ar a registered protessienal engineer ALTFR� � F�NAL � g � .�V(��.7 z .ticting in my professiona) mpaci�y (Section 7051, ❑ �ATE .i�� RFPAIR Business and Professions Code). USf OF nFMOL ❑-� F�NAL . ��.� i"�J -� EXISiING RLOf. � Lit.or Rr.g.No. ___D�te' nPPLICANz . TE! BY ��f � � OWNER-BUILDER DECLARATION 1?RINPy•MCG1riR1S yaItFHE)1Z3�.�- � i ne�ebY af+��R,rt,o�i om exemp�+�om�he co�„a�rors u�e�,se 22900 Golden Springs Diamond B law for fhe following reason (Section 7031.5,'Business and �DDR@SS � �a�afess�o�s code>: PeeseNr �,1 �5,7 A ❑ BUILD�NG � � � I, os owner of the property, or my employees with ADDRE55 }`,�o e • m o '� wages as their sole compensation,will do the work and � � - ihe sirudure is not in�ended or oftered for sale(Section I-OCAUTY � ` - . + e ��,� �a 7044,Business and Professions Code). MOVING � lt�. - � � ❑ CONiRAC7UR NO. E � � ��y' I,as owner of fhe property,am exclusively wniracting e(j.I, ��;� wiih licensed contractors b consir�ct fhe prajecf(Sec- qDDRESS tion 7044,6usiness nnd Professions Codel, Q'� 1 p...�; CUNSTRUCTION LENDWG AGENCY RE4UIRED TOTAL SETBACK FRonn eXlgi. . SCT 6ACK YARD HWY pROP_L!NE WIDTH I hereby affirm ihat there Is a mnstruUion lending agency for FRONi the performnnce of the work fo�whi<h}his permli is issued P.l. (Sec.3097,Civ.C.). � SiDE � none P� Lender's Name ... / {,P.G Fee"� �U�� Permit fee �/-�", Lende?s Address_. _ � . i cerrify thar I have read ihis applimtion ond stote thal the Issu <e Fee ��'� � = above information is correcf.I agree to mmply with all County �' Imes�ionrlon Fee an !� .�� � ordinances and State Inws reloting ta building consir�ction, Toial Fee �P � � and hereb authcnze�ep esentatives of this County to enrer zupor ove-mey� oned pro ri for inspection rpo s. - - - � i _�y � ���,.s./' C G ' SEE REVERSE FOR EXPLANATORV IANGUAGE " '� ��� � � Signahira of App ican�or A,enl ate . � . �s . .y. .e. _ —_,. ,_�..... .'� ._ _. ..-.-..._ .e..._.v_ - _ .._... __ "- _�. _ _....,..... e ..._.. .., ._�_.. .._......._. _ � E�.'�. 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