HomeMy WebLinkAbout1569A 1570A (9) WORKERS'COMPENSATION DECLARATION � I�
I hereby affirm ihat i hnve a certifimie of consent to seff �PPLI�ATION �C�I� �UILDING PERMIT �
.insure,or a ceqifimfe of Workers'Compensfion Insuranr.r.,or .
a certified copy thereof(Sec.3800,Lab.C.1
Pou�yNo. 7634-811�mpony Pac. Indemnity �OUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Pv v FOR APPLICANT TO FILL IN a�oeess d A`'+-K�>-
Certified ro is hereb furnished.
� Lertified copy is filed with the county building inspeo- 6UILDING
r�oo deparime�f. nooaess/�5 Bld . 24 228 '1 �oca.urv �-��
Diamond Bar 91765 "EARtsT
Dale n�Pi�mnr S. McGinnis cirv zic ceoss sT____ _ �
CfRTIPiCATE OF EXEMPTION FROM WORKERS' NO.oF aIDGS. ASSESSOR
COMPENSATION INSURANCE 5¢E O�LOI Now ON LO7 p MAP e00K PAGE PARCEL
(This sedion�need not be mmplete2l if the permit is for one USE ZONE MAP t � _�
hundred dollars($100)or less.) TRACT 36346 stocK �o�No. No. �� � � y.
- TEL. SPECIAL fl.
i ceriify.iho��n rhe performance of ihe work for wh�ch rh�s ov�rdeR AhmanSon Dev. No.8i88i4 I5 coNoirioNs �
ermit is issued,I sholl not em lo an erson in an manner flISTRICT GROUP TYPE FIRE PROCESSED BY �
� P P Y Y P Y � �� CONST. ZON[ �
�so as to become subjetl lo ihe Workers"Compensation Laws. ADJRFSS
�;TY Irwindale �,P 91706 � `� "� �' �
Date Applicnnt SIATISTICA�CtRSSiFICATION APT. CO O. gj
ARC.HITECT OR T L. g,�
NOTICE TO APVUCAM� If, afler makinc� this Cer?ificate of EycWEeR B&E En ��
i32545134 anss No. �weLL.uNiTs o.
Exemption, you should 6ecome subjetl-to the Workers' - a91
, Compensaiion prov'i5ions of ihe�.abor Code,you must forih- ADDRESS SEWER MAP �
ith tomply with such provisions ar this permit sha�l be .
deemed�e�oked. - coNrancroa Ahmanson.Dev. Ti�148371279 e�� P�, vauonnotu
LICENSED CONTRACTORS DECLARATION � � tIC �
1 hereby affirm that I om Ikensed under pro�Isions of Chapter 9 nDDRESs 23$(1 E+j T O No.�l. VALUA�TjION - +, c,�;Q�S
(commencing with Sectio Y/OOQ)J of Division 3 bf the Businessnnd ���' �� a�P U� f'�a
Profes'sions Code,and m ii<ense is m full force ond effect CIIY FSI. 1�OT0 CLA55 �-1 � iG�
' S0_I-I. NO.OF NO.OF CHECK �' � � �� t
LicenSeNumher 4G,SFiRR('_R!' �'ic.Class R—'I SIZE ' S10RIE5 FAMILIES ONE
Trash Enclosures n;ew � $ � � `i 4`'�
Conirnttor �mdRSOR �2V. pn�y- - �ESCRIPTIONOFWORK . � �
� 1 am exempt from ihe licensing requirements as I om� . ADD � � ' � E �i,'�-�
licensed architect or o regisfered profess�onpl engineer A�TER � OA EL i1 ,�},� U r'' ���u`� �
acfing in my pro{essicnal capacity (Secfion 7051, REPAIR ❑ �
Business and Professions Code). U56 OF � �. PINAL -
EXISTING BLDG. DEMOt BY t� �
lic.or Reg.No. D<ale APPUCANT iEL d .
OWNER��BUILDER DECtARAT10N (PRINT)S.MCU'1riri1S NO.]]_1F$(j1Z31 �� .. �
�1 �LUA
I hereby affirm that I am exempt from ihe Contrcr<toi s license �
Law for ihe follcwing reasan(Section 7031.5, Business nnd _ ADDRE5522J�� GO�. 2 $ YlR S 1 � � � � •'
Professions Code): - , PRESENT
aBLIIL�ING - / '
I, as owner�f the property, or my employees wilh ,�DDRESS t � '�L����i,Ci
woges as their sole compensaiion,will do ihe work ond � ��
the slructure is not intendad or offered for sale(Seciion- � tOCALIiv � . g � �o(��,����
7044,Business ond Professions Code). � MOVWG 7EI._ ' •
� CONTRACiOR NO.
I,os owrer of the property,am exclusi�ely coNraciing U �, 1 �—�.�7
with licensed contractors to consiruct the project I,Ser qDDRE55
� tion 7044,6usiness and�Prafessions Cade). �
CONSTRUCTIONLENDINGAGENCY SE7�gqEK YARD HWY �TOTAPR�PACIKEFROM �jp.H
� I hereby affirm thot ihere is a construction lending agency 4or FkONT � �
�the performance of�he work for which ihis permlt is usued �L �
� (Sec.3097,Civ.C.1. � SIDE
P.L.
Lender s Name riOnB -
� Lender's Address �P-G Fee S l �t Perm��i Fee ..���--3�� � �
I certify thai I have read ihis applimfion and stale that the iss�.�nnce Fee �—'S�
y ��
y �above Informalion is correct.I cgreo b comply with all County �Ir'invesilgmlon Fee . -
� orainances and State laws relutinc�io building consiructfon, � 7atal Fee � -G�
� and hereby aufhortze represanfativ of this County to enter �
n �pon ihe ove�menii n d pro. y f r inspecflon pµrpose ���yy7 � �
i ^�t, .� ' �� SEE REVERSE FOR EXPIANATORY LANGUAGE -
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