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��
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