HomeMy WebLinkAbout1561A 1562A WORKERS COMPENSATION DEQARATION �
� ; hereby c°fL�� ;;ru' �eve a wrtiiicate of consent to scit A��LI�ATI�iV FOR �UIL�ING PERMIT �
insure,or a certificQfe�of Workers'Compenstion Insurance,or �
�� a cerrified�opy therPof(Sec 3800,�ob.C.) COUNTY OF LOS ANGELES BUILDING AND�SAFETY
i P�i;�YNo:763/+-8118c�,,,pa„Y Pac. Idemnity
Certified co -s hereb fumished. BUILDING ��r t�� ,,
' ❑ r�v� v fOR APPLICANT TO FILL IN aooeess .27-� ��J:o�r-.� /�-.-�
I� Certified ropy is fi�ed with the counry building tnspec- gUILDIN ]_
, � +�o�deParrmenr. Auukess 22879 Ailton Head iocaurv �-�•
� S.MCG111R15 NEAREST
Date Applicant - Ciiv ZIP CRO55 ST.
CERTIRCATE OF EXEMPTION FROM WORKERS' NO.OF 6LDG5. ASSESSOa
- COMPENSATION INSURANCE SIZE OF LOT NOW ON LOl O MAP BOOK PAGE PARCEL
(This seciion need not be�completed if the permit-is for one USE ZONE MAP �
hundred dollars(�100)ur less.) iRACT RLOCK LOT NO. NO. �l � � �
TE SPECIAL - �
!certify!hat in ihc parformcnce of fhe work for which ihis ��'NER �?R3IISOP.D2V. N�188147�-rJZ CONDITIONS �
. permlt is issued,f shall not empYoy any person in any manner DIS7RICT GROUP- TYPE FIRE PROCESSED 8Y �
nb�aess1001 Commerce Dr. �L coNsr. zoNe
so os to become subject to ihe Workers'Compensation Lows. �a '7_ C C�
(7lt.(� � ` �
� Dote Applicant � C�Tv ZIP ; 51/�tISTICALCLA551FICATION APT. ONDO. � �
NOTICE TO APPLICANT: If, afrer making ihis Certifimte of /+RCHITEC7 OR TE� �
exe«��r+o�, yo� s�o��d be�a�„e sobj�a ro �t,e wo�ke�s Ev�i^E�R B&E En Nc.2132545134' anss No '�-�S owei�.uNiTs_ �
Compensation provisions of ihe Labor Code,you must forih- ADDRESS 82 rj (,'OZOTfl(10 Blud. LA 90041 SEWER MAP �
wlth tomply w�dh such provisions or lhis permit shall be �
deemed revoked. . cONTRF�CTOR Ahmanson Dev. �a48371279 gK. P6, VALIDATION
LICENSED CONTRACTORS DKLARATION - ���, -
I here6y affirrn�hot i am licensed�nder provisions ot Chopter 9 � ADDRESS N VALUATION
(commencing wrth Section 70W)of Divislvn 3 0��he Business and i�� �s
aroFess�o„t cod�,o„d my r�P�_s��s.n f�u+o«e�.�d effe�r. cirr El Toro aassB'� � a�s+L�[� i 5 6; Fh
1f6SE1HSGBG 8-�- SIZEFT STORES g AMI�[$ � CONE G:
License Num6e� Lfc.Class h.m e o u[1
$
�ESCRIPTION OF WORK T'Z'a,5 EIICIOSllT29 N`� � -/
co�+�o�i�� Ahmanson D�v.__om�_._ � t m H � 2 5�1
� I or xempt fro r it licen. g reyuirernents qs I am a ��� � � ,.,� -z.
lic d archit -.o a registe d profess onal Pngmeer aiiER �• FINAL p - y. ii-c_-
acting in my p ofe slonal npacity (Section 705, � DATE �1 �� �
REPAIR
Bosiness and Professions Code). USE OF � ., � '�'i �-L� .
� EkISTiNG 9LDG. f)EMOL �' BINAL� .
LiC.or ReCJ.NO. ___Date_ . APVLICANT TFI Y �� �
�OWNER-BUILDER DECLARATION (Pe�,M; 5• MCG1riril5 ��I�FH61.Z313.�.
I hereby a(firm jhat I om exempl from ihe Conirqctor's License �� . .
Low for ihe following reoson (Section 7031.5, Business ond ` AUDRE55229 (�i0�.{t6II $pTlI1QS Diamond Bar
Professions Code): � pRESEN � z T J�t����
❑ Bl11LDING A � .b .
I, as owner ot ihe property, or my employees with AOORP55
woges os�heir sole cortipensa+ion,will do ihe wark and �'� � �7 �
the structure is not intended or offered for sale(Section LOCALITY R �
7044,Business and Professions Code). - MOVING 7EL. - � �� a °�i��,�fl
� I,as awner of fhe property,am exdusively conYracfing � CONiRACiOR NO. . o �{' S ,_
with licensed mntrpcfors fo construct ihe projed(Seo � ���zJ�.
t�on 704A,Business and Professions Code). AD�RE55 y .
REQUIRED �(J7AL SE�BACK�ROM EXIST. : ' � � r•? G a��
CONSTRUCTION�EN�ING AGENCY SET BACK YARO HWY PRON.LINE WIDTH � -
I hereby affirm thnt there is o mnstruction lending tigenry tor FRONrr
�he performance of ihe work for which ihis permit is issued p.�. � �
(Sec.3097,Civ.C.). SIDe - -
none P� �
Lender's Name �
� _� _ �P C ree S� ���`,��..,Pe.mi�Fee ��-..�T� �' - .
Lender's Address . � .
' i certify ihai I have read ihis oppllmlion and state tha+the d- issuo��e Fee � � S�� 1� �
i .aSoe�e inforrr�atlon is correct.I agree fo comply with all Counly ���,�esriga�ion Fce � -
ordinances and Sfate�aws relating to buildino consiruction, To+al Fee ��`� �
and here6y authorize representatives of ihis County to enier �
' upon ih ove-me iqned prop rty or inspe<tion p pos/ey. . -
i ---/��'a""„""_"-___�su�Y/� � , . SEE REVERSE FOR EXPLANATORY IANGUAGE ' . . .
' � Slgnar�re o4 Aopi�mnt or Aqen� rc �P 5 .
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