HomeMy WebLinkAbout1565A 1566A (9) WORKERS'COMPENSATION DECLARATION � �
I hereby affirm that I have a certificate of conseni to self
.insure,oracertifimfeofWorkers'Compenstioninsorance,or APPLIC/�TI�N �OR �UILDIN� PERMIT
a certified copy thereof(Sec..3800,Lab.C.) � � �
Pou�yNo. 7634-811�Fy,mPa„y Pac. Indemnity COUNTY OF LOS ANGELES BUILDING AND SAPETY
❑� BUILDING �� �p,� ��� B
Ce�tified copy is hereby t�rnished. FOR APPLICANT TO FILL IN ADDRCSS �y l�tz-C.�eti !M�—�-'
� Certified copy is flled with the co�nty b�ilding insper gUi�DINGJt �
tion depariment. - ADDRESS 7r3 $ld . ZLF ZZH79 H11t.0Il Head �ocnurv 1�-�j • .
NEAREST
Date npp��m�,r S_Mr�inniG arv Diamond Bax �iP 91765 � cuosssr. �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLOGS. aSSESSOR
COMPENSATION WSURANCF size oF�or Now oN�or MAP BOOK Pnce vaRce�
(This section need not be completed-if the permii is for one USE ZONE MAP t .^���f
hundred dollars(stoo)or�ess.) , rencr 36346 eio:K ioT No. No. �,
ltL. SPECIAL (g,
�certify that in ihe pertormance of ihe work for which this u��Ntk �.m nS011 17CV N CONDI710NS �
permii is issued,I-shall nof employ ony person in any manner DISTRICT GROUP ?YPE FIRE PROCESSEO 6Y �
so as ro be�or„e sobje�r ro the wo�kP�s Compensption iaws. Aooaess 1001 Commerce Dr. �� � covsr zoNe �
cirv Irwindale Z,� 91706 f""� ' �
�Daie Applicant � STATISTICaI CIA551FICATIDN AP7. ON00. {�j
NOTICE TO.APPLICANi: If, after makir,g this Certificate of ARCHITECT OR �TgL" _ 4 �, �
exan,puon, you sho�id beco�.,e sub�ed to the workers � ENc�"�ER B&�' En �. e�.i254S134 � cwss Na +'�-�' ov�Eu uN�rs �
Compensation p.o���s�o�s ot�he tUb�r coda,yo�r�,�s�torih- -�,��kEss �� $25 Colorado LA 9C1041 sewee nnnP � �
with�romply with such provisions�or this permit shall be
deemed revokPd. . CONTRAG70R m N' BK. PG, VAL�DATION
� LICENSED CONTRACTORS DEC�ARATION LiC �
I hereby offirm that I am licensed under provisions of Chop�er 9 ao�aess 23861 El Taro No.46$688GBC VALUATION
(commencin �th Secilcn 7000 of Dlvisior.3 of ihe Business and .. � n O� r
Professions Code,and my license is in full force and effect. � ���y E1 TQTO � �ASS B—�. $ a z I ::G..•�, ,
-� SW.FT. N(J.OF NO.OF CHECK +7¢ C a �['�
uce�se Nu�.,be� C�hShRRARC i�<.Cinss R—1 s¢e sroeies Fannwes oNe
Ahmanson Dev. oEsckiviicN oF woRK Trash Enrlosures NE'^' � $ Y ' ° 7 u."4
Coniracfor �pte ❑ ��
� I am exempt from ihe�iCensing fequiremenfs tl5 I am a ' ADD e _� � � y,`;�,,.:�j --
licensed architect or a registered professionnl engineer ALTER � FINAL
acting in rcy professional copacity (SeUion 7051, � DATE ���� Li(,� ����j
REPAIR
Business and Professions Cade). USE OF pFM�� � FINAL
' E%ISTING BLDG. By qA: f�i
Lic.or Reg.No. Da1e APPiICANT T9 d t�'_p- - .
OW'NER-BUILDER DECLARATION (PRiNiI 5. MCGlriri15 N�JZ4S61Z311 . .
I hereby affirm ihat I am exemp�from ihe Controctor's License � y
Low for ihe following reuson(Section 7037.5, Business and .A��RF55 ���90Q GOZdEII S T1R s Diamond B3 �1 �E�E`�-
Professions Code):, PRE EN? . � � . -
� 1. as owner of the P Y, Y P Y ���IDING � � . . `� . . . . r;�$ 6 m � e.�
pro ert or m em lo ees with ADDRESS
wages as iheir sole compensation,will do the work and I e s[F�..�1.(; .
ihe strudure is nof intended or offered far sale(Seciion �OCALIiY -
7044,Business and Professions CodeJ. MOVING TEL . ; q F ��� z n -
❑ CON7NFlC70R NO. � - ""�'�'''
I,os owner ef the property,am exdusively contracting
wiih licensed contractors to consiruci the project(Set- qDDRE55 �'�� n'��'5 �
. tion 7044,Business and Prafessions Code). - � .
CONSTRUCTION LENDING AGENCY RE(:UIRED YARD HWV TC]TAL SETBACK FROM EXIST .
SET BACK PROP.IINE N/I�TH
I hereby offinn thot ihere is a wnsr�ucfion lendiny agency for FROM � - �
the perforvnance of ihe work for whi<n this permit is issued p.�_
(Sec 3097,Civ.G�. . SiDE �
r.�
Lender's Name
���� P.0 Fee$ 7erm���Fee �����
Lender's Address____--__._ _
w I certify that I have read this application and state that the IssuanwFee �� ����
Qabove Information is correci.I agree to comply with all County Inves�ig�tion Fee � _
oralnances and State laws relating to building consiruction. Total Pee ��'� �
� and hereby authorize representative of ihis County tc enter , . - _ �
� upon bove-me t" nad pr5�per �nspaction purpos s. . '
a . �Ji'C.p� at���___li�// . SEE REVERSE FOR EXPLANATORY IANGUAGE � . , ,. . .� �
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