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�.'�. I'P1'fi (1= ' T' ('P7 T (R T � r' C!i ^'d TY . ..
i. � � � O � Q � fl Q � f7 n ❑ CJ Ot} �;q � .�. � � p O � �
m rz � y �' �s � 3 � � �Q T p � ;; � � Q a. � � Q
� . O I n N � C7 `G � - p fl O � � Q Ll CJ � � > � � �
��� � z x �.� .� ,r-� � � �.. ....a �. co � '� n
j �T �� � O-Q usi o Ip I � Q �3 (l� 9 " �� @ �
{ � C � Q e4 9 O%
� � O � O Q Q 4 � p � O q � . Q (�j' '�
Q i ' a' Q. w � � � ro I � 3 ° 4 �
� N v Q �n (D (d � �
�. �
p' �
� J '
m
`. "'_ Q �
� r
• ��y q � �
�',
i�,,.e �- � - — �
. �� � . . � � o �
� �-�_ — — -�- I e � �i
;� � � -, �
c �
� � � � �
i� .� � � 3 � p ' �
� t w 9 � �. �
°�
(� �Q I! &9 . - � �
�� . j� d �^ . . . - �. . � � � �,
� � �'� �� ^
� � � �
� � � � �
i � �� �
� 43
�A.
- �_ v
1
�i
r
�
'$
�
�
�
�
�
�
�
�
�
�
p
�
j r .
tl
v °Cr o-l�,v � �� S�b n t��-F 'ea A �n„ �... o ��'py o--
� � Q � �V.��..'� A� �� Y M � C o �'� .�l � (� � ��� iY a'S +�t � �' �� � N�T
° i n �'x'.'� '.� � A m � �� �� � �A m �.�o p-.sa'g .�� � m
� � n � c � b..: � ��,m ��� �� � � �b �O O c�� A � � m m
Q �., y �,,� s-°w g K A `�",�, y�n " 3 Q � O a c� � o"�v,•«��" " �Q
� h`�•�a � � ma ��' � m�' �.'° oa.�. mo o � aho�����' �. � °,�
x t,,,`r-�i �- w � � '°`'�'zs a„A o �. �yy m n � P.�;,�'a �.,`"'� �.;y � Ry =�
� ,�•� n � io � � r.�w m :�� �: � � o :�.a b c� � o y a o 3 �
3 ee C a � �m � � �; � ro b, c o o � � '� o N �a � M:� e��'
� 'O p c10, � � ., eo Qv o'A.� � 3 �_` a A � y' lw C+n �, m
2 c � � ea. o R�p o �a�, � •O � �`� « 3 � o e�o'e> `° :^. A� � � � �.�, s Q�
°�v g �`"a v�o�a �' �' �:,o '�b, � � � � 3 a v`�"� �� � nx S� � „ � -t=s
� � i o o��o-° �aa '�,m,�ta'� '��'°���� � �'�� a Q� ��.� � °3 �
� ��� �.N ° o-�a m � mc N � w+� os,v,°� �. � o � o 0
' � � s'� ° � o �° �.� p mA�,y �� ,mR'o Q� ��o•�� �� o :'o,�^. �a 7.m t�
� a` N� �, " n � � � �' �°=° -�o `' � o'�. °0 a o q,�ca 3 tM
` ` 'n° �o n� o °. �" °� ro o �m'�c � � � o ���;�� ,� � � n
` � �0� �� 3 cx�.� aC �'�' n�-� �` mm�°'A �° o `0 " � a p �`r3
° O �e • -^. x � 'y°a� w`°``'�° o� o=� ia`A m x `m' � � rA, R a'`� ° 3 �
b o '� � ��a H��a A. � d Hyb n dY� � �' x 2s. 0 3 r
3 � � � °���'y o o �a.h � � a � � m °w°��s,s � �� � o �s sy
'� � s Q� 8 < �.��A'r,a`�� `� co�� �A � m-.�` �� �,r�.m o in� O
:° Q �'Qn, �o � � e."� ,o' " �� �w o w � "b rsa o +n .� m C1 a
• � �p .� .-� '� �. , h ",a v.��"f�G -�."'p� .� v,�n o A,*� `•' as
. � �Y ;� � n d � S,a`' n � �a �„n � � e�„� e.v"'�°,�.a M � `°� �
O O y � n � 7 �° �9 .5 �o�'Z1 Q'*i V�y q p °^`+a ti �� Q '� O �* O Q
� � � . a. � � � m o �, o .`�M� �fl � ���"ti o�o ro �•h� W o
s rn r , � � o ���� o �.,�v� - � a-a „ � ww � o,
N W v O L,�• `R P� lD '°'. +n (C f2 S n:�2 N bx �n ` �v a