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HomeMy WebLinkAbout1567A 1568A WORKERS'COMPFNSATION DECLARATION ti `--��Y°„"�� '��°�' �QOz��°�}�`��°}e°`���SeOf��=P" �►PP�.I��►1'ION FO� gIJILDIIVG PERMIT insore,or a certifimte of Werkers'Campenstion Insorance,or � o tertified mpy ihereof(Sec.380Q Lab.C.) � Por�yNo. 7634-8118o,,,Pa„y Pac. Indemnity COUNTY OF LOS ANGELES BUILDING AND SAPETY � 6UILDING Ayt: ey �)_ff+,�- Certificd copy is horeby fomished. FOR APPLICANT TO FILL�N aooeess r� e � xrr.��r�- [] Certitied copy Is tiled with the county building inspec- BUILDWG ��4 B�-d 24 228��9 �g�`� H1�.COri H .t �.-�^ ��,� tion deparfinenf. ADDRESS g� lFJ�ALITY ' � NFARfST � Doie npplicam S.McGinnis oTr Diamon B ziP S cRosssr CERTIFlCATE OF EXEMPTION PROM WORKERS' NO.OF BLDGS. a55E550K COMPENSATION INSURANCE SIZE OF LO7 NOW ON LOT MAP 800K vAGE PARCEL (lhis sPction need not be mmpleled if the permit is far one USE ZONE MAP J�{�_��j hundred dollars($100)o�less.) iencr 36346 s�ocK �oi No. No. ! )' � TEL. SPECIAL � ^�n�n=R Ahmarsan Deuel, uo.81$ 1 1 coNoinoNs � I certify;hct in ihe periorma�.ice of ihe work for whiCh ihis DISTRICT GRCIUP TYPE FIRE . PROCESSED BY e� permii is issued,I shnll no1 employ nny person In any manner qD�RE55 - CONSL 70NE so as fo bemme subject to the Workers'Compensation Laws. )d _ . � arr Ir�aindale ziP 91706 � ' ` r Date Appli[ant �RCH�TECT OR TEL � STATISIICAL CtASSIfICATION APT. C DO. �j NOTICE TO APPLICANT: If, after makiny this Certi(imte of �N"MEER $&$ EII i$:�..3Z5 51 CLASS NO. �"� pWE��.UNITS_ � Exemption, you should become subject to the Workers' . . gn Compensation provisians of the Ldbor Code,yau must forth- qnnRESS $Z,�j �0.1.0 HC�O 1,�1 JD��F1 SFWER MAP � � � with comply w�th such provisions or fhis permii shall be deemed reveked. ThL' gK p�, � VALIDA710N � CONTRAQOR Ahmanson Dev. � No714$3 12 LICENSED COMRACTORS DECLARATION �Ir. i he,ehy aff�,m ir,�+i�m u�e„s�d��dP,�,.���.s���s of cho��Pr e nooRess 23861 El Toro No.465b$$GBC VALUATION . (corrmiencing with Secllon 7000)of Oivision 3 of the Business nnd - - LIC. ,n Pro{essions Code,and my license Is in£ul(force and affeci_ GTv j'+,l TOIq � CLASS B—�. � �b�� SQ.FT. - NO.OF NO.OF CHECK z I F�1 I Y- �;�o„seN„mbe� 465688GBC it�.c�ass R-1 srze sioeiEs Fann�ues orve $ ;�o � � s��� conr�o�for Ahmanson Dev. o�ie oEscNiancN or woRK NEw � I am exempt from the licensing requirements as 1 am a . AD� � & i S�:J�a� licensed archited or cr r=gisiered�rofessional eng�neer . ALTGR �� FINAL �� � Q e r � r��U DATE ' aciing in my professlonal capacity (Section 7051, RCVAIR - Business and Professions Code]. � USE OF . ���,�v� � PINAL ��� i ``�� � EY,ISiING BLDG. Lic orReg.No. Dote � APPIICAM 7E - BY r���-����`- � OWNER�-BUILDER DECLARATION (FRiNi)S_MCG1Iii116 N�],�{$()12,3�.]_-� I hereby affirm that I am exempt from ihe Contractor's License t qpDRFSS 22900 Golden S rin �s D13fi0IId Pi3T Low for the followinq reason (Section 703L5, Business and Professions Cai1e;: .PR_SCNT - � ❑ BUILDING � - I, os ownar ot the proparty, or rny employees with aDDRE55�,.. � � ` '�'� woges as their sole compensation,will do ihe work and ,.}m � o � ,� the structure is no�intended or offirred for sale(Section � tOCn�iiv _ 704a,Business.and Professions Code). .MOVING ieL , z�� � . � I,as owner of the property,am exclusively conYracting CCNTRACTOR NO. � � j a o Q.„5(j�,j wifh licensed confroctors to cnnstruct ihe projeci(Seo- qoDRESS r> a �(1� � '' - tion 7044,8usiness and Professions Code). ��U Z��-' REQUIRt� TOTAI SfTBACK FROM EXISf • CONSTRUCTION LENDING AGENCY �SET BACK YARD HWY pROP.L!NE WI�TH -, - �J 7�'� C)...�� I hereby aNirm Ihal t4iere 1s o consiruction lending qgency fo� FRONT ' the perforrnance of ihe work for which this perrnit is issued a.�. . (Sec.3097,Civ.G). SiuE � - � 7 i. tender's Nome_. NOI72 - . __ _ . , ` " . ° Lender's Address___ �. P.c PPe.$ � '�G Pe. �i Fee ��—`� �.- - . � I cartify ihal I have reod this appl-cation and staie fhot the �� Isso �e Fee �� `�5�� ` . `- above information is correct t agree}o comply w-16 all County 'I esii9ation Fee � � ordinances and Stote laws relating to building construdion, 7otol Fee ��� � . - dnd hereby outhorize representotives of ihis Co�nty to enter . . oupon th bave ment�oned prop y inspeciion pos . � . 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