HomeMy WebLinkAbout1571A 1572A (9) � WORKEkS'COMPENSATION�ECLARATION �
�' ' `—e`vy oiiirm inaf I have o cen�ifimfe oF consenf to self q�p�l-�qT1�iV FOR �tJILDING PERMIT � '�
� insure,or a wrtifimfe cf Workers'Compenstion Ins�rance,or �
a certified copy thereof{Sec 3800,Lab.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY
P❑ol�cyNo. �mpony Pac. Indemnitv
Ce�tifie c�opy is�e�eby f��nished. FOR APPL�CANT TO FILL IN no�kEss �Z��� �,.���.r+., ��i
� cernt�ed�opy is filed w�,n rnP�o��,y b�ad�n9��s���- euao�n��p6 B1d 24 22579 Hilton Head ,[�_v'3 �
tion department� A�DRESS g' LOCAIJTY
NEARESI
oore nppn�anr S,McGinnis c�rr Diamand Bar ziP 9ll65 ceosssr.
CERTIP�CATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. ?55E550e �
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT O MAP BOOK PAGE PARCEL
(This setlian need not be complered if Ihe permif is for one USE ZONE MAP - ����i�o
h��d�ed do��ars�$too�o.�ess.) rRncT S$gS3634 iocK �oT No. No. �
� iEL. � SPECIAL . �
I ce���`y that in;he perforrnunce or`tne work for which this �°��A1C° Ahmanson Dev. uc.818814715 CONDITiONS �
p y any person in ony manner UISTRICI GROUP fYVE FiRE PROCESSED�BY
pe�m�r�s�ss�ed,i sh�l��or em �o noozess 1001 Commerce Dr. corvsi. zoNe �
so as io 6emme subjecl ta the Workers'Compensation Laws. '�� - �
�iTr Irwind�le ZiP 91706 >� �
Dafe Applicant—__ � ------ ' �STATIST�CALCLA551FICATION APT. C DO. �j
NOTICE 70 APPLICANT: If, after making this Certificoie of ARCh'I7ECT OR TEL.
Exemprion, ycu should bemme subject to the Workers' ENGWEER B&E Eri . '�']_32�j rj].3 � CtA55 NO. DwEtL UNitS_ �
CompensntiCn proe�isions of the Lubor Code,you must(orth- qDDRE55 I,E1 Jd��{Z SEwER MAP �
.wifh comply wi�h such provisions or �his perrni� aha�l be '
deemed revoked. � cONTR�QOR [�hipgriSOri DgV. `��77I+$4]1�79�,. �K� �'G- _ VALIDATION
LICENSED CONTRACIORS DECLARATION i��. .
I here6y afBrm that I am li<ensed under provisions of Ch�pier 9 ' aD�RESS , NO. � yqtUAT10N
(mmmencing with Section 7Q�Oj of Division 3 of the 8usiness and ��C. / �� G 7
Professions Code,and my license is in full force and effect. ��iy E1 Toro CLA55 $-1 S �,46 �� � ' ' � k
SQ.F1. NO-OF NO-OF CHEIX
LicenseNumber �.Q��.RR��R!` LIc.Clqss B`1 SIZE SIORIES FAMILIES ONE �e `� �����
, � NEW � .� ( e e 'I n,.J L�
co�o-a�ro, Ahmanson Dev_oare oEscR�Pr�oNOFwoRK Trash Enclosures
� I am exempi from the licensing requiremenis as i am a AD� � �.� , �e;C�.1_
licensed architeci or a regislered professionol engineer. . AUER .� P�NAL . � �� � -
acting in my professional capacity j5ection 7051, R'ePAIR � DATE �� ��� �� � �,_�rJ
Business and Prcfessions Code). , USE OF ���„��� r'l�- FtNAI - .
. EXiSTWG BLDG. L.J By f/'!1 /�)_ _
Lic or Reg.Na Dale ArvuCAN7 TEi. g��-ye�—�� �
0�1�NfR-BUILDER DECLARATION (Nk���T1$ �- No.
I hereby offirm that I am exempt from tha Contractor's License 22904 Golden S Z'1 ri S D13ID011d B3I' � �
Law for fhe followinq reason(Section 7031.5, 8usiness and ` ���RESS P � g . � - V�'G Z�
Professions Codc): aRF ENT
❑ BUILDiNG J ' -t:;'° ° o '� � 1 .
1, as owner ol the prcperty, or my employees wiih ADDRE55
, wages as 4heir sole compensalian.will do the work and
ihe stru<lure is not intended or offered for sale(Section LUCALiTY � - J�b �j�,�C LJ
70A�,Business ond Profess�ons Code). � � MOVING � 7EL . . � �_
� I,os owner of the proporty,nm�exclusive�y conirocfing CONII2ACTOR NO_ a e m[!�,�(.1�
� wfth licensed mntrnctars to mnstruU the projeci(Seo - ADDRE55
tion 7044,Business and Professions Ccde). _ ��� 9'�"i J
CONSiRUC�TION LENDING AGENCY �EQUIRED �AR� HWy iOlAl SElt3ACK FROM EXIST -
SET BACK PROP.LNE WIDTFi �. -
I hereby affirm tha�there i,a construction lending ogency for FROnI' .
ihe performance o(the work for which rhis permir Is issued P.L � -
(Sec.3097,Gv.C.)_ SIDE .
PL
��„de�'s rvn�,e none
�P� �ee$ I�`..� Fermil Fce ��..�—z�
Lender's Address Y - .
I certify ihot I have read ihis application and stafe�hat the �` iss���nce Fee !�"�� �
iabove informntien is correc�.I oyree to comply wlih all Counfy `-investigation Pee �
ordinances and State laws relaling to building consirucrlon, Toial Fee ��� �
� and hereby au�harize representativ s of�his Couniy fa enter �� - -
iupon t bove mryrrt ned pr, I for inspectlon.purp es, . .
eJ�j�{� f [�, SEE REVERSE FOR EXPLANATOftY LANGUAGE �. � .
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