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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 - Signawre oY Appli�a�ii or Aye� D te .� Os r � � � .. � � �T� x' A � � , R � iP ��'e � a � � C� � 4�3 � O- .p � p'W � �w e�¢, c9 O � .R�.o-,. *6 lD � > n. �m � g., o n �e -tl � -" � ¢ r-¢ n� f� � �io � � � « �, -n Ui O 'S2 � Zr N g� � �: � 6� � p � � .� Q b � �' " 1A -�a Q C' 6,"'-• � N O� �� r� �e ..Q 6 � � � � '� 0 1r= � � �' � � S �^ �(D a• � � � �� � � � � � �c � � O � m -� � � � � �o ¢io o fn ��:c � ¢ a� � '� g� C�' d°� � a ` ` 2 x o� � � o' " '� � � w 9'� � 3 R'c `D, � 9 � .-/ n 4� �r' '�1 o 0 3s p � a � c� � co � ��' �\ o ° s�,,, � � �� .,� o� � � � �� �4 � � � � . �� � � ' q��4 .. � f1--� � . 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