Loading...
HomeMy WebLinkAbout1563A 1564A (9) y � WORKERS'COMPENSATION DECLARATION - . � � - � , - ._ , _. . _ __ . .. . s, I.hereby offirm.Jhal I hove a certifwate-of-consent to self ���L���CA�I�ON.��FOR� �.B�JIG_DtNG PERMI�` � ��� insure,oca cer�ificate of Workers'Compensption Insurance, ' or a certrfied copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES • BUILDING.AND SAFETY � aou�y.rva.. 76�4-811cgmpany Pa�. TndPmnitc � -�Ceriified�co s hereb .furnished. - BUILDING �y �y� (t /J•s- Jj e ❑, PY' Y FOR APPLICANT TO FIIL IN ADDRESS � / r+-�G-�r�- jy.o.a_ti�.c- � �� Certified copy s fNed v✓ith ihe counfy-building inspec- BUILDINGJ t ��� �1 � "tion�department. ADDRESS YrZ B1dg. 24 22879 Hilton Head 6_ S.McGinnis � oote qpp��ca�r ciTv Uiamond Bar ziv 91765 �ocnurr CERTiFICATE OF EXEMPTION FROM WORKERS' -� �- NO.oF atoGS. -. NEAREST .- ' ` COMPENSATION INSURANCE � SIZE OF LOi NOw ON LO7 O � CROSS 57. � (This�seclion-need�no��be completed i4�fhe permit is-for-one ASSESSOR . � reacr 36346 eiocK ior No. hundred dollars($100�or.less.j MAP BOOK PAGE PARCEL TEL USE ZONE MAP .. I certify_ihof in'ihe performance of ihe work for which.this O'riNER [Lhma,nSOR 1JflV. N ND. / �- 7�� '.} � permit is issued,I shail noi employ-any person"in any manner SPECIAL � � so as io become subject to the WaFkers'Compensation-Laws. /+ooRfSS CONDITIONS v oore qPPI;�a�, arv_ Ixtaindale_ ziP ��0x 9170 m � NOTICE TO APPLICANT�lif;after makin �this'CerHficate of .ARCHiTECT OR TE� DISTRICT GROUP TYPE FIRE PROCESSE�6Y -�._� e ENciNEER B&E Eng. No2132545134� � Exemption,-you should-become subjecr to the Workers' _ �r CONST. ZONE � Compensaiion pra�isions of iha Labor Code,you mu5�fOlih- qDDRE55 HZ6 COZOY'c`1C10 }�IVd. LE� 9�Q41 �� �'�.� . �a •vith:�mmply.wifB.such:.provisions oc.ihis.permit shall be-- � TE� �.t�1 deemed revoked. . . . . .... CONTRACTOR At1IIL8.'C1SOTt Dev. No7148371279 �TAiISTICAI CLASSIFICAFION . � APT.� C N60. �� � LICENSED CONTRAGTORS OECLARATION ���, . � CLASS NO. �� OWtLL UNITS , I here6y affirm thot I om licensed under provisions of Chapier 9 � ADDRE55 Z3SE71 EI. TOTO RCT. NO.tFClSE1HHGBG SEWER MAP (commencing with Seciion 7000)of D'vision 3 of ihe @usiness and UC. � Professions Code,and my.ticense is in fuil torce and effeci. � CrzV EZ TOTO a/+ss B-1 BK. pG. YALIDATION - ' SQ.FT. NO.Of NO.OF CHECK - Li[enseNUmber 4h5b$�iC'RC' Lj[.GaSs R-1' SIZE STORIES FAMILIES ONE � -� �'`�� VALUATION � L:t11R3RSOIi DC'V. OESCRIPTION OF WpRK �.�? � ��� _, Contrdctor Dafe NEW O . s � �, . . . . ADD ❑I am exempt under Sec � - ; F-�`� � ALTER . . � . . I 8.8P.C.for}hic reason . .$. . . . . ._ . .. REPAIR ❑ � �� d�"--�t' i , Date: � USE OF '�EMOL � '. . . . - E%ISTING BLDG. ' _ .{.. (.v.W 4' ... �'� � $i at�re � APPLICANT , TE . . ' 9n OWNER-&UILDER DECIARATION _. PRIN7 S.MCGIRRIS � N�14$(12311'. f��'�'<<�fy ' -�-� ' DATE �r'J .. ...s_ I �.�'�i�u,;x�_. 1-hereby affirm fhat I am axempifrom�iheCom�actor's License � 22900 GOZGlEri S T1R 5 DlamoRd $a. �- 1 - � Law for the following-reason(Section 7031.5, Business and AODRESS � �' fINAC � ^ 3 '� �c` Protessions Code):.. .. .,. . . .. ., . ... �_'... PRESfNT . ... . . .. .... ... .._. . .._..... .__'$y f�::-f +..____.�.::- .. . e 4'_.7<3 �1"'i>J�" , - �BUILDMG � � �, as owner of ihe properfy, or my employees with ADDRE55 � � wages as�heir sole compensation,will da the work and �OCALITY :, -_ Ihe structure is not intended or offered for sale(Section - �. - 7044,8usiness and Professions Code). MOVWG TEL � � -- � ��� ��� �--��-� � �t�(�-� �- � I,as owner of ihe proparty,am extlusively confracting � �CONTRACTOR NO. - . with licensed conhacfors fo construd ihe project(Sec- qDDRESS - � - - `-'{"¢-� a�a m c�'�---- � � lion 7044,Business and Professions Code). �' REQUIRED 70TAL SETBACK FROM ., � � CONSTRUCTION LENDIN6 AGENCY ���--� SET BACK YARD HWY pROP.LME WIDTH `� - �:e s� u��� ���� I hereby affirm that there is o<onsiruction lending ogency for FRONT � � �the performance-of the work for which this permit irissued p.t. ': - �__a.. �.-ty.v�.�.; (Sec.3097,Civ.C.). SIDE . � . R4IIE � P.L . ....�/..� n.-'H:.�. ._.. t.%. Lender's Name � � ,-� LDMA Ref.H . . . - . - Lender's Address - � - P.C.fee$ f Permit Fee ��--� � - 1 certify�hat I.have read this applicotion and.state ihat ihe . Issuance Fee l� ' `�^� LDMA P/C k - '-�- -- ¢ above informafion is correct.I ogree to wmply with all County InvesYgation Fee u� o�dinances and Stale laws relating to building construction, Tobl Fee ��'� LDMA Germ.M � - and hereby authorize representatives of this Caunty to�enre - W upon tF ove-meM' ed prop for inspecfion p po s. . � - a ,�P7��1..�$' � ^ �,�.a.2'.-.-•��r �� SEE REVERSE POR EXPLANA70RY LANGUAGE . � - - Signafure of Appl cant or Agent - te - . . . 'C�� 0 0 T Z Q ,O. � a N � N .. . , '*`co �D o. O 'S Ci r nb �m o � v � `^ o 0 p � �j� ��� tQ. `fl 4 .Wp �, 4 H � Q n Q .Q Q � � G . -n U+o � II' J n� � 3 iD a '� � o -o ? N r' ,r cn o �o n �° Q Q� o o � y r j Q 6 � 4 O b � p� � � - N Q ° � 3 Q F� �a � �; � mT o o s s a° `° ap� o �� a 2 O �;,o• �,� c } 3 p �c o � a � p q, co Q �m m m-2 N '" Q N 'z p .o ° sp? � °4 � °� o. -� p � � ��" 7, -0 3 'o T q � w � � t� � ° � �D � � �' o o- ?i ��-, Q', Z � � d o 0 n '� �'.-^� � �J �� �0 � ' � — P v W � 'O Ot W G' �^ q �� i�,,,�, ' � fl'� V~ '�}"' � . . . . l.� N �� � � � ' i' C , � � .. . . . - , . . . Z 'NO T � 0 P N z � N ' eC � - ,��� y C73��. � �.,..-� �0 y.m � .a � .. . _ �. '� �fl"'o o� � " �� =��m �. 6 ��,3:`z �'a ,G m��c ��Q.y �. �-< v ' " �.b' -Cs P y W c0 � .p-.."PC �U,C �w' �-...p P �-� � '�l ': '.- a.'�L C � ' � N 'L .� � p t.+ P ,'3� p„ �,"2 � -' � �� �-�e m���A'H nn _ c��x — �,.�r�, � 'ti o3 `,�� .. ' . , � ti O A, OC � 'n `—.� �o � o m : (�:i � e� p cP.:�4 m p � � S� n p � 5 fl � � � . �"� �. y �.c:� ..? " »� v '� � �`-•,� � � � � m � o � �'`��d� � n SgG Q O (J �¢ � Gy..5'l o`^o S_ o.�''u; -: 3 � � c •H.p�? � ����c N �C^ ., ' � O r. .� Y p� �.a m v�b a-n � m�o �°tD +�cs� k ° � y 3'� N `^ �3 r� " � '� m o ,�� N c� � �'T'>y �D o `� a `Y A � n�*m� n '� ° ,�`„ '� � r � � ° r • � o v w ?. n "+ � � w S A .� .w o o m � s 'sv �.'� � m� �..�c � a�o c� � _ o m � s c�.`� `� o �x• � ° �� � m G . . x' r.t� r ;, " o" "� r.� x « p b y o.v m � � e s�-..� � � o _ � .� rx � � � � ,� �� n o �� Q-� na.3 0 � ,�a„-Q� m�` o �'-� -o C �, % a o ,. .6. �, o � ,.d 3 s s-� o 0 o N v � .. m ti,�Y'^ m`z m -^Y � r"p � �'v�-�..°-�a A o ,.��a.� o� `-�°- o oj � �� omc'� ��� .,��^i o3y . p.. a �o'`y y o o� ta.� -� ° ��a° � � o r � � o a � ? Y � c0 i' � � �.'G '^ '^"4(9 . L"m L �'c} � O `T� O� A.m�'� ,t'„ '� :..�n �`� � � � � O O �t �.,10 N �L c� Cn .m y•OC m � �" - � . T N `�P Q 'n �"< O 3'e� � � 'G' n� `L S�,b � �A a �, m A tc � n p L � :.' ^ "P.� C�j � � �y.�.��.p..F.n o�� � � � O,�.a A p.� o A"Q'�3 ?. ��,°- � s� R'c � a.� `�°�o� p m m% a Q ��Q o � s.i' � o � o�Q �� a n x �,, ,L o �.. p v.,,_,�....� � �3„ o Z c�. � ,.�, = o � � ,,.,,� m- -°~u+ £.� �o r,��, s n� Y.N. � '��+ O � � �� �c.�"�' t�0-� �..��� "'.3.�.�� Oc�in 0 p �`� 5 �� � y S'.7 � p _ v� p� t��° m ,.~�y a. . � � �,N. �= � �c a.'�� . � w � N o,.� o o,� o �a',�a'�o � � o,n • F�"z � s' �,m n A '� . �:, D Q S�.. m � ��.,tD-s `+ .^. � m o - 7. c Q'�°'' ,,,....�. - o s ��:,,<. -e � �� � � o m o -�i.m m � ,�,.....-,� O � 5.-t_n /.. �s o �, �!�.,-- s ,� �„.�---" l__.,,_ �✓,..---^'. �.-��- .��. �.---" /_�_...--""��..�-�--. ✓t.-^-„"_ �..-'-.'"'.�--f